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Bronchiolitis

SOAP NoteWith this assignment, you will demonstrate your ability to document a clinical encounter in the widely accepted SOAP note format. The SOAP note will…

SOAP NoteWith this assignment, you will demonstrate your ability to document a clinical encounter in the widely accepted SOAP note format. The SOAP note will be based on the given clinical case scenario detailed below.
Clinical Case ScenarioDx: Bronchiolitis
A 12-month-old presents to your office in January with a 2-day history of runny nose and cough. The child now has wheezing with nasal flaring and retractions, and his oxygen saturation is 89%. There has been no fever, and several of the other children and adults in the family have had a cold over the past several weeks. On examination, you hear scattered wheezes and rales. Allergies: NKDA
To complete this assignment successfully, you will need to read the assignment instructions and accurately address each criterion.
Assignment InstructionsAll SOAP note assignments will follow the format below. Your SOAP note must follow the APA format and should include a title page, in-text citations, and a reference page.
SUBJECTIVEHPI
Document the information given in the caseInclude a list of relevant questions you should ask in order to obtain any missing informationRemember OLD CARTS when completing this task.ROS
Document any symptoms given in the caseInclude a list, per body systems, of classic symptoms specific to the given diagnosis.You may refer to your textbook or other resources to complete this section.OBJECTIVEVITAL SIGNS Include a list the following vital signs that correspond to the age of the presented patient document what is given and assign a value to what is missing based on age.Height & Percentile; Weight & Percentile; Temperature; Blood Pressure; Heart Rate; and Respirations
PE
Document any exam findings given in the caseInclude a list, per body systems, of the classic physical examination findings specific to the given diagnosis.You may refer to your textbook or other resources to complete this section.ASSESSMENTDx
List the given diagnosis with the ICD-10 code. Include a brief description of the pathophysiology.List TWO differential diagnosis with their ICD-10 codes. Include a brief description of the pathophysiology and a rationale for the chosen differentials.PLANLabs
Document any lab results presented in the caseList any tests youd like to ordered include the reason for the test and what it will showPlan
Document the information given in the caseDocument your treatment and management plan based a National Clinical Guidelines.You may NOT use your textbook for this; only clinical guidelinesMake sure to include:
Vaccines administered this visitMedication-amounts and mg/kg for medicationsPatient education about the condition including preventive care and anticipatory guidanceNon-medication treatmentsFollow-up appointment with detailed plan of f/uReflection Include your thoughts about the given case. What did you learn?
The completed SOAP note should be submitted to the appropriate assignment link.
Submission Details:

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