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*NURSING > Final Exam Review > NURS 6541 SOAP Week 10 (All)

NURS 6541 SOAP Week 10

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CHIEF COMPLAINT: Sore throat SUBJECTIVE: Seen in the office today a 6-year old boy with complaints of a sore throat now for the past three days. The boy and mother reports the child having issues w ... ith inspiratory breathing and chest pain especially at night. The patient started having sneezing and coughing starting last night. A barking cough was heard last night as reported by the mother. Congestion and coryza was present. The patient denies any headache, earache, stomach ache, nausea, wheezing, vomiting, or diarrhea. OBJECTIVE: No known allergies. No recent hospitalizations or surgeries. The child is up to date on all immunizations. T 98.4 orally, BP 100/70, pulse 85, RR 14, spO2 99% on room air, weight 60 lbs. The patients’ appearance overall looks healthy and well with no acute signs of distress. No inspiratory stridor observed, no accessory muscles being used. Tympanic membranes appeared WNL and intact bilaterally. Clear nasal discharge was noted with red, irritated bilateral turbinate’s. No lymphadenopathy observed or palpated. Lungs clear to auscultation anteriorly and posteriorly. No adventitious sounds. No rales, rhonchi, and wheezes. Heart sounds RRR, no murmur. Abdominal examination normal, active bowel sounds x 4 quadrants. All extremities well perfused with full ROM. Pt appears to be developing appropriately and reaching developmental milestones. [Show More]

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