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NR 602 WK 5SOAP NOTE FORMAT - JO
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NR 602 WK 5SOAP NOTE FORMAT - JO
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NR 602 WK 5SOAP NOTE FORMAT - JO, NR 602 WK 5
SOAP Note Format - Jo
Patient Information:
J.F., 6y/o Caucasian girl
S.
CC (chief complaint) – “Vomiting, diarrhea and fever”
HPI: 6 old girl p/w vomiting x2 days/diarrhea x1 day/fever 100-101degrees/severe lower abd
pain x1 day. Last meal was at a pizza buffet 36hrs ago, otherwise no solid foods since then,
consumed sprite, apple juice and popsicles instead. Administered Pepto-Bismol (OTC) & Tylenol
x2-3/day for fever. There are no other associated symptoms. Endorses that pt urinated this
morning. Of note, pt’s brother is having similar symptoms. Otherwise no symptoms, aggravating
or relieving factors identified.
PMH: Jo is continuing on Ritalin, 5mg daily since you began her on this several months ago and
is doing well. She has not had medication in the last two days. They both have been well since
their last visit.
Current Meds:
Ritalin 5mg PO daily (missed 2 doses 2/2 vomiting). Used to treat ADHD. Monitor for stomach
pain, nausea, vomiting, loss of appetite, vision problems, dizziness, mild headache, sweating,
mild skin rash, numbness, tingling, or cold feeling in her hands or feet, nervous feeling, sleep
problems (insomnia) or weight loss.
Chewable MVT w/ Iron. Multivitamins are used in the prevention/treatment of vitamin
deficiency and are usually sold OTC as dietary supplements. Children's chewable vitamins with
iron are less likely than adult preparations to cause serious toxicity, caution should be taken when
giving a child MVT with Iron because acute iron poisoning continues to be a common and
potentially lethal ingestion, especially in the pediatric population.
Allergies: NKDA
PMHx: Full-term gestation, born cesarean section, wt 7lb 4 oz (mother smoked 1 PPD
throughout pregnancy)
ADHD – diagnosed 2015
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