Assignment Prompt & Instructions
Ø **Sprain/COUGH/COLD/FEVER/ IMMUNIZATION/ ASTHMA/ABDOMINAP PAIN**
Ø **Well-child visit**
– 2 years ago
**files (1)**
– ## SOAP_SAMPLE_HMWM.docx
**## SOAP_SAMPLE_HMWM.docx**
**This is the teacher sample, so pls do not repharse, just create new once, i want you to create. OUT PATIENT ONLY.**
**10 short SOAP notes similar to this one in PEDIATRIC patients only. Presenting to the clinic With different condition for al ages from 0-17 years of age.**
·
**Sprain/COUGH/COLD/FEVER/ IMMUNIZATION/**
·
**Well-child visit**
·
**Include Vital sign, Head circumference, for infant, and new born. Percentile stages.**
·
**Please include RTC date.**
·
**Asthma**
·
**Including any issues that a pediatric will present to PCP visit.**
**SAMPLE 2**
Well Visit Female:
S: 5-year-old hispanic female seen for abdominal pain x 3 days, more severe with food intake stated that pain is intermittent, No associated vomiting, diarrhea, or recent dietary changes reported by the parents. Fever noted at home (T: 100.5°F). No other systemic symptoms reported.
O:VS: BP: 111/65. HR:84. RR: 17. Spo2: 98. Ht: 48’’T:100.5, Wt: 63.2 lbs – General: Well-nourished, well-developed female in no acute distress. HEENT: Normocephalic, PERRL, no oropharyngeal lesions, TM clear. CVS: No murmurs. Respiratory: Clear to auscultation bilaterally, no wheezes or rales. ABD: Soft, non-tender, no hepatosplenomegaly. MSK: Full ROM, no deformities. Neuro: Alert and oriented, normal gait. Skin: No rashes or lesions.
A: Abdominal pain, likely due to constipation. Fever – Likely associated with viral illness.
P: Discussed sleep hygiene, social skills, and healthy diet choices. Educated parents on warning signs, including worsening pain, persistent fever, vomiting, bloody stools, or changes in behavior.Encouraged parents to monitor bowel habits and stool consistency. RTC in 1 week or sooner if symptoms worse
**SAMPLE 2**
**S:** 8-month-old Hispanic male with
**worsening wheezing, cough, and increased work of breathing** x 2 days. Mother stated that he became
**lethargic, less active, increased cough, and had a weak cry; no** fever, vomiting, or recent illness.
**O**: Vitals: HR 155, RR 50, SpO₂ 93% on room air, BP 88/50, Temp 98.3°F, General: Lethargic, weak cry, minimally interactive. Respiratory: Subcostal retractions, nasal flaring, diffuse wheezing, decreased air movement. Cardiovascular: Tachycardia, capillary refill of 2-3 seconds. Neurologic: Fatigued, responsive to stimulation but weak.
**A:** **Severe asthma exacerbation with persistent respiratory distress despite initial treatment**
**P:** Albuterol and ipratropium nebulizers were administered with minimal improvement. A second albuterol nebulizer was given at 30-minute intervals, with persistent retractions and tachypnea noted. Due to ongoing respiratory distress and lethargy despite treatment, the patient was transferred to the ER via EMS for further evaluation. A report detailing the treatment administered in the office was provided to EMS.
**## SOAP_SAMPLE_HMWM.docx**
**This is the teacher sample, so pls do not repharse, just create new once, i want you to create. OUT PATIENT ONLY.**
**10 short SOAP notes similar to this one in PEDIATRIC patients only. Presenting to the clinic With different condition for al ages from 0-17 years of age.**
·
**Sprain/COUGH/COLD/FEVER/ IMMUNIZATION/**
·
**Well-child visit**
·
**Include Vital sign, Head circumference, for infant, and new born. Percentile stages.**
·
**Please include RTC date.**
·
**Asthma**
·
**Including any issues that a pediatric will present to PCP visit.**
**SAMPLE 2**
Well Visit Female:
S: 5-year-old hispanic female seen for abdominal pain x 3 days, more severe with food intake stated that pain is intermittent, No associated vomiting, diarrhea, or recent dietary changes reported by the parents. Fever noted at home (T: 100.5°F). No other systemic symptoms reported.
O:VS: BP: 111/65. HR:84. RR: 17. Spo2: 98. Ht: 48’’T:100.5, Wt: 63.2 lbs – General: Well-nourished, well-developed female in no acute distress. HEENT: Normocephalic, PERRL, no oropharyngeal lesions, TM clear. CVS: No murmurs. Respiratory: Clear to auscultation bilaterally, no wheezes or rales. ABD: Soft, non-tender, no hepatosplenomegaly. MSK: Full ROM, no deformities. Neuro: Alert and oriented, normal gait. Skin: No rashes or lesions.
A: Abdominal pain, likely due to constipation. Fever – Likely associated with viral illness.
P: Discussed sleep hygiene, social skills, and healthy diet choices. Educated parents on warning signs, including worsening pain, persistent fever, vomiting, bloody stools, or changes in behavior.Encouraged parents to monitor bowel habits and stool consistency. RTC in 1 week or sooner if symptoms worse
**SAMPLE 2**
**S:** 8-month-old Hispanic male with
**worsening wheezing, cough, and increased work of breathing** x 2 days. Mother stated that he became
**lethargic, less active, increased cough, and had a weak cry; no** fever, vomiting, or recent illness.
**O**: Vitals: HR 155, RR 50, SpO₂ 93% on room air, BP 88/50, Temp 98.3°F, General: Lethargic, weak cry, minimally interactive. Respiratory: Subcostal retractions, nasal flaring, diffuse wheezing, decreased air movement. Cardiovascular: Tachycardia, capillary refill of 2-3 seconds. Neurologic: Fatigued, responsive to stimulation but weak.
**A:** **Severe asthma exacerbation with persistent respiratory distress despite initial treatment**
**P:** Albuterol and ipratropium nebulizers were administered with minimal improvement. A second albuterol nebulizer was given at 30-minute intervals, with persistent retractions and tachypnea noted. Due to ongoing respiratory distress and lethargy despite treatment, the patient was transferred to the ER via EMS for further evaluation. A report detailing the treatment administered in the office was provided to EMS.