Pediatric SOAP Note #5- 4583-20240621-008

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

-Patient:

10 year old Asian male

an already established patient at the clinic

-chief complaint:

 shortness of breath

 

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

Patient is a 10 y/o boy here with his mom. Complains of shortness of breath for the past year, but states since recent dx with COVID (one month ago) he has been feeling SOB more frequently the past week. SOB symptoms occur during rest, with exertion and goes away on its own.  

 

-diagnosis:

Covid 19

shortness of breath

-Diagnostic test

Flu swab

strep swab

covid swab

 

-Education:

-Educate on COVID-19 safety measures and the importance of notifying close contacts.

-Encourage rest and isolation

-increase fluid intake

-Monitor oxygen saturation with a pulse oximeter

-instruct parents on signs of respiratory distress that would necessitate immediate ER visit, such as severe shortness of breath, persistent chest pain, or new onset confusion.

 

Medication

-OTC tylenol for fever and discomfort

-corticosteroid

-albuterol inhaler

 

Plan

-refer to pulmonologist for SOB

-Encouraged to purchase SP02 monitor to record oxygen level when episode reoccur

-Return to the clinic is symptoms reoccur or new symptoms present.

 

denies food allergies, seasonal allergies, medication allergies

 

 

Denies surgical history

Denies hospitalizations

Denies traumas

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