week3-B

Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

· Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

· Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.

· Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

· Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

· Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

Office Visit 6/11/2020

9-year-old African American Male present to clinic with his mother for Asthma exacerbation. per mother patient has been wheezing a lot lately but this morning he started complaining of Shortness of breath. Per mother patient has been out of his medication now for few weeks.

Treatment:

Proventil HFA 108 (90 base) MCG/ACT inhalation aerosol solution, 1-2 puffs every 6 hours as needed for SOB or wheezing (use with prescribed spacer), montelukast sodium 4mg oral, 1 tablet daily at bedtime, albuterol sulfate 0.63 mg/3ml inhalation nebulization solution every 4 hours as needed for SOB or wheezing.

F/U at the clinic in one week.