Assignent Solutionnurs

Instructions: Please be sure to write the SOAP note as though it was a real patient and include all relevant information.
SCENARIO: Parents bring in their 4 month old daughter with complaints of nasal congestion, cough, irritability, and fever for the last 2 days. They state that the cough was louder today and that they noticed the child was breathing faster today so they brought the child in to be seen. The child is up to date on immunizations and was seen 2 weeks ago for their 4 months well-child check.
TIPS FOR ASSIGNMENT: For your Review of systems, you want to include pertinent positives and negatives, that would be more than one symptom in each body system.
Physical exam: please document your findings and avoid using terms like “wnl” or “no remarkable findings”
You should always have three differentials with evidence based rationales and be sure to indicate what your final diagnosis is.
Lastly include your National Standards of Care