What details did the patient or parent provide regarding the personal and medical history?
A 3 y/o African American female who present with her mother with a complaint of coughing for a week.
Mother reports that she has been coughing every night. She has also had a mild fever of 100.5 at home. Her mother has been using a decongestant/antihistamine syrup and albuterol syrup at home from her previous prescription. Initially the cough improved but it worsened over the last 3 days. She is noted to have morning sneezing and nasal congestion and she goes to pre-school where some of her classmates were noted to be sick. She has no know allergies and up to date with immunization. Previous medical condition is asthma that has been controlled by albuterol inhaler and Nebulizer as needed
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?
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