pediatric SOAP Note #4- 4583-20240622-006

Please provide the requested information on the template and enter the information on the template form attached.

-Patient:

13 year old black male

an already established patient at the clinic

-chief complaint:

seasonal allergies

-history of patient illness (please add more information to cover OLDCARTS format):

Has a history of asthma and seasonal allergies. Went to bible camp and came back home sneezing, body aches, and not being able to smell. Take albuterol as needed, qvar, and zyrtec daily with some relief.

-diagnosis:

seasonal allergic rhinitis

-Diagnostic test

Flu swab

strep swab

covid swab

-Education:

-avoid allergens

-take medication as prescribed. Do not take rynex with the zyrtec because they have some of the same medication

-encourage wearing a pollen mask during high pollen days if spending extended time outdoors.

-increase fluid intake

-hand hygiene

Ordered medication

-Rynex

-Flonase as needed

-continue albuterol

-continue qvar

-continue zyrtec

food allergies- peanuts

seasonal allergies- pollen, grass, mold

medication allergies-none

Denies surgical history

Denies hospitalizations

Denies traumas

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