Soap note 1:ped

SOAPNOTE1_PEDS.docx

SOAP NOTE 1

S: 8yo Hispanic female with epigastric pain x 6 days, Pain is intermittent, non-radiating, and worsens after eating. No vomiting, fever, or diarrhea. Reports mild nausea and poor appetite changes. No recent illness. No sick contacts.

O: VS: BP 102/64 mmHg, T: 98.6°F, HR 88 bpm, RR 18, General: Well-appearing, no acute distress, Abdomen: Soft, mild tenderness in the epigastric region, no guarding or rebound, no distension, HEENT: No pallor, no signs of dehydration, Respiratory: Clear breath sounds bilaterally

A: mild GERD and constipation

P: Encourage small, frequent meals, avoid spicy/fatty foods, increase hydration and fruit

Monitor for worsening pain, weight loss, bloody stools, persistent vomiting

RTC in 7 days or sooner if symptoms worsen

NUR 638 SOAP NOTE GRADING RUBRIC

		Point Breakdown	Points Earned
Subjective History	Includes: Age of patient Chief complaint HPI Pertinent past medical history, allergies, current medications	30 points
Objective History	Includes: Vital signs Physical exam Labs and diagnostic studies/results	20 points
Assessment	Diagnosis	20 points
Plan	Includes: Medications (prescription, OTC, herbals) in full prescriptive format Dosage calculation parameters (ex., mg/kg divided bid) Non- pharmacologic treatment Patient education Follow-up	30 points

			Total Points:

SoapNote_yinka_sample.docx

Soap Note 8

CC: “Patient present to the clinic for diarrhea, persistent anal pruritus, and irritability.

HPI: HPI: A.S. is a 23-month-old Male with no significant PMH. He presented to the clinic with his mum and aunt with c/o diarrhea, persistent anal itching, and irritability for 3 days. The itchiness is worse at night and after bowel movements. The patient had an episode of diarrhea at least 6 times a day and started getting better yesterday. He moved his bowel today 2 times, but it is still loose. He was drinking fluids and eating well. Denies blood or mucus in the stool. Mum reports a history of rash, which has resolved with diaper cream. The family recently traveled to Bangladesh in May and came back in August. The patient had similar symptoms in Bangladesh and was treated for roundworm with a medication called Solas in Bangladesh. Denies cough, runny nose, fever, or vomiting—no other kids with similar symptoms.

Past Medical History: Generally healthy, up to date on vaccinations. No prior history of gastrointestinal infections.

Medications: None currently.

Allergies: No known drug allergies.

VS: T: 98.1 Wtan : 27lb 6oz Pulse: 198 Ht: 34.06" 2'10.06" HdCir: 19.0 HdCir cm: 48.3 Resp: 38 O2SatR: 98

General: Well nourished, alert and well developed. Weighs within the normal range. No signs of acute distress present. Mucous membranes are moist and pink.

Respiration: Chest expansion is symmetric. Clear to auscultation. Lungs are clear to auscultation bilaterally.

CV: S1 S2 is normal—regular heart rate and rhythm. No murmur, rubs and gallops appreciated.

Abdomen: Active bowel sounds, abdomen is soft and no mass palpated. No umbilicus hernia noted.

GU: Perianal area show sign rash and erythema. Firm, rounded buttocks and patent anal opening.

Diagnostic

Stool test for Ova and Parasite Pending.

Assessment and Plan

Enterobiasis

Medication

Reese Pinworm Medicine (Pyrantel Pamoate suspension) 144mg/5ml. Give 2.5 ml by mouth once, repeat in 2 weeks if symptoms continue for pinworm infection. The patient dosage calculation followed the manufacturer recommendation on weight based calculation by pounds. It is recommended that infant between the ranges of 25-35 lb takes ½ teaspoonful which is equal as 2.5ml. (Wt 27lb, 12.41kg)

Education

· Counsel parents on hygiene practices to prevent reinfection (e.g., handwashing, keeping nails trimmed).

· Take a shower or bath every day (in the morning is best).

· Counsel parent to wash patient clothes, towels, and bed linens often.

· Counsel parent to monitor patient and ensure patient is not scratching around your anus or between your legs.

· Encourage fluids and pedialyte to restore fluid and electrolyte due to diarrhea for the past few days.

· Will call the lab result and treat as necessary

· Return to clinic if pruritus get worse after treatment or bleeding through the perianal.

SOAPNOTE1_PEDS.docx

SOAP NOTE 1

S: 8yo Hispanic female with epigastric pain x 6 days, Pain is intermittent, non-radiating, and worsens after eating. No vomiting, fever, or diarrhea. Reports mild nausea and poor appetite changes. No recent illness. No sick contacts.

O: VS: BP 102/64 mmHg, T: 98.6°F, HR 88 bpm, RR 18, General: Well-appearing, no acute distress, Abdomen: Soft, mild tenderness in the epigastric region, no guarding or rebound, no distension, HEENT: No pallor, no signs of dehydration, Respiratory: Clear breath sounds bilaterally

A: mild GERD and constipation

P: Encourage small, frequent meals, avoid spicy/fatty foods, increase hydration and fruit

Monitor for worsening pain, weight loss, bloody stools, persistent vomiting

RTC in 7 days or sooner if symptoms worsen

NUR 638 SOAP NOTE GRADING RUBRIC

		Point Breakdown	Points Earned
Subjective History	Includes: Age of patient Chief complaint HPI Pertinent past medical history, allergies, current medications	30 points
Objective History	Includes: Vital signs Physical exam Labs and diagnostic studies/results	20 points
Assessment	Diagnosis	20 points
Plan	Includes: Medications (prescription, OTC, herbals) in full prescriptive format Dosage calculation parameters (ex., mg/kg divided bid) Non- pharmacologic treatment Patient education Follow-up	30 points

			Total Points:

SoapNote_yinka_sample.docx

Soap Note 8

CC: “Patient present to the clinic for diarrhea, persistent anal pruritus, and irritability.

HPI: HPI: A.S. is a 23-month-old Male with no significant PMH. He presented to the clinic with his mum and aunt with c/o diarrhea, persistent anal itching, and irritability for 3 days. The itchiness is worse at night and after bowel movements. The patient had an episode of diarrhea at least 6 times a day and started getting better yesterday. He moved his bowel today 2 times, but it is still loose. He was drinking fluids and eating well. Denies blood or mucus in the stool. Mum reports a history of rash, which has resolved with diaper cream. The family recently traveled to Bangladesh in May and came back in August. The patient had similar symptoms in Bangladesh and was treated for roundworm with a medication called Solas in Bangladesh. Denies cough, runny nose, fever, or vomiting—no other kids with similar symptoms.

Past Medical History: Generally healthy, up to date on vaccinations. No prior history of gastrointestinal infections.

Medications: None currently.

Allergies: No known drug allergies.

VS: T: 98.1 Wtan : 27lb 6oz Pulse: 198 Ht: 34.06" 2'10.06" HdCir: 19.0 HdCir cm: 48.3 Resp: 38 O2SatR: 98

General: Well nourished, alert and well developed. Weighs within the normal range. No signs of acute distress present. Mucous membranes are moist and pink.

Respiration: Chest expansion is symmetric. Clear to auscultation. Lungs are clear to auscultation bilaterally.

CV: S1 S2 is normal—regular heart rate and rhythm. No murmur, rubs and gallops appreciated.

Abdomen: Active bowel sounds, abdomen is soft and no mass palpated. No umbilicus hernia noted.

GU: Perianal area show sign rash and erythema. Firm, rounded buttocks and patent anal opening.

Diagnostic

Stool test for Ova and Parasite Pending.

Assessment and Plan

Enterobiasis

Medication

Reese Pinworm Medicine (Pyrantel Pamoate suspension) 144mg/5ml. Give 2.5 ml by mouth once, repeat in 2 weeks if symptoms continue for pinworm infection. The patient dosage calculation followed the manufacturer recommendation on weight based calculation by pounds. It is recommended that infant between the ranges of 25-35 lb takes ½ teaspoonful which is equal as 2.5ml. (Wt 27lb, 12.41kg)

Education

· Counsel parents on hygiene practices to prevent reinfection (e.g., handwashing, keeping nails trimmed).

· Take a shower or bath every day (in the morning is best).

· Counsel parent to wash patient clothes, towels, and bed linens often.

· Counsel parent to monitor patient and ensure patient is not scratching around your anus or between your legs.

· Encourage fluids and pedialyte to restore fluid and electrolyte due to diarrhea for the past few days.

· Will call the lab result and treat as necessary

· Return to clinic if pruritus get worse after treatment or bleeding through the perianal.

SOAPNOTE1_PEDS.docx

SOAP NOTE 1

S: 8yo Hispanic female with epigastric pain x 6 days, Pain is intermittent, non-radiating, and worsens after eating. No vomiting, fever, or diarrhea. Reports mild nausea and poor appetite changes. No recent illness. No sick contacts.

O: VS: BP 102/64 mmHg, T: 98.6°F, HR 88 bpm, RR 18, General: Well-appearing, no acute distress, Abdomen: Soft, mild tenderness in the epigastric region, no guarding or rebound, no distension, HEENT: No pallor, no signs of dehydration, Respiratory: Clear breath sounds bilaterally

A: mild GERD and constipation

P: Encourage small, frequent meals, avoid spicy/fatty foods, increase hydration and fruit

Monitor for worsening pain, weight loss, bloody stools, persistent vomiting

RTC in 7 days or sooner if symptoms worsen

NUR 638 SOAP NOTE GRADING RUBRIC

		Point Breakdown	Points Earned
Subjective History	Includes: Age of patient Chief complaint HPI Pertinent past medical history, allergies, current medications	30 points
Objective History	Includes: Vital signs Physical exam Labs and diagnostic studies/results	20 points
Assessment	Diagnosis	20 points
Plan	Includes: Medications (prescription, OTC, herbals) in full prescriptive format Dosage calculation parameters (ex., mg/kg divided bid) Non- pharmacologic treatment Patient education Follow-up	30 points

			Total Points:

SoapNote_yinka_sample.docx

SOAPNOTE1_PEDS.docx

SoapNote_yinka_sample.docx

SOAPNOTE1_PEDS.docx

SOAPNOTE1_PEDS.docx

SoapNote_yinka_sample.docx

SOAPNOTE1_PEDS.docx

SoapNote_yinka_sample.docx

SOAPNOTE1_PEDS.docx

SOAP NOTE 2 : PEDS