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Soap note | Nursing homework help

Patient Information: Initials: J.D. Age: 7 Gender: Male

Subjective: CC: Fever and cough HPI: J.D. is a 7-year-old male who presents to the clinic with a chief complaint of fever and cough for the past three days. He has been feeling tired and weak, with a decreased appetite. J.D.’s mother reports that he has had a low-grade fever, ranging from 100-101°F, which has not responded to over-the-counter fever reducers. He has also had a persistent dry cough, without any mucus or phlegm production. His mother denies any recent sick contacts or travel history.

PMH: Asthma, allergies

Objective: Vital Signs: Temp 100.2°F, HR 96 bpm, RR 20, BP 108/68 mmHg, O2 saturation 97% on room air. General: J.D. appears tired and weak, with decreased eye contact and a mild dry cough. Lungs: Clear to auscultation bilaterally, with no wheezing or crackles. Heart: Regular rate and rhythm, with no murmurs or gallops. Abdomen: Soft and non-tender, with no hepatosplenomegaly. Skin: No rashes or lesions noted. Assessment: J.D. presents with fever and cough, which is likely due to a viral upper respiratory infection. The cough may be related to his asthma, but he currently has no wheezing or shortness of breath.

Plan:

1. Recommend supportive care, including plenty of fluids, rest, and fever reducers as needed.
2. Discuss the importance of good hand hygiene to prevent the spread of illness.
3. Prescribe albuterol inhaler to be used as needed for any asthma symptoms.
4. Follow up in 3 days to assess for improvement or worsening of symptoms.

Education:

1. Discuss the importance of good hand hygiene to prevent the spread of illness.
2. Teach J.D.’s mother how to use the albuterol inhaler properly and when to administer it.
3. Advise J.D.’s mother to monitor his symptoms and bring him back to the clinic if he develops any shortness of breath or wheezing.