NRNP 6568 Week 9 Assignment; Diagnosing, and Treating Special Populations
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Soap Note
SUBJECTIVE
Patient Information:
Patient Initials: AN Age: 9 Years Old Sex: Female Race: American
CHIEF COMPLAINT (CC): “runny nose, For Annabelle, 99.4 degrees is a high fever.”
HISTORY OF PATIENT ILLNESS (HPI)
AN is a 9-year-old girl whose mother accompanies her to the hospital. The mother states that AN, for the past three days, has been having a running nose. Additionally, ANs mother says that AN woke the previous night complaining of pain in the right ear. The mother took her temperature orally. The temperature was 99.4 degrees Fahrenheit which is equivalent to 37.44 degrees Celsius. Therefore, she decided to give AN Tylenol which helped reduce the temperature. AN’s temperature reduced to 98 degrees Fahrenheit, which is equivalent to 36.667 degrees Celsius. The mother is concerned about AN temperature of 97.0 degrees Fahrenheit, equivalent to 36.11 degrees Celcius. According to her, 99.4 degrees Fahrenheit is a high fever. The mother also states that AN is not eating well but is drinking well. The mother also says that AN has had a couple of loose stools which did not have blood.
PAST MEDICAL HISTORY (PMH)
Allergies: No known allergies Current medications: Tylenol. Injuries: no
known injuries Patient’s Illness: fever.
Information Related to Past Surgical Procedures (PSP): no known Surgical Procedures.
Family History (FH): AN’s family history is not known. There are no details about the siblings and the father. However, we know that she has a mother. The mother’s health status is not known.
Social History (SH): AN social history is not known. There are no details that show the patient’s relationships with friends or family members.
Review of Systems (ROS):
Constitutional: Positive for runny nose, pain in the ear, loss of appetite, loose stool with no blood.
HEENT: Positive for pain in the ears and running nose, negative for ear discharge.............. Continue
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