mixed up Soap Note for the case below

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Advanced Health Assessment

Mixed up Subjective Data Work Sheet
A.M. is a 3-year-old female who is presenting to your primary clinic setting with her mother.  AM. is an
existing patient, and she is here for a sick visit.  Her complaint is “fever and sore throat.”  
Vitals: Temp:  38.9 C
HR: 128
RR: 24
BP: 100/72
Height: 32 inches
Weight: 15 kg
1.  Read the rest of the case study below and then complete the blank Soap Note attached to the
scenario.  Use only the information provided.
a. Decide what is pertinent and then place the components in the correct sections of
subjective and objective components
b. Use appropriate abbreviations and concise terminology if appropriate
2. Consider the following questions
a. What type of history will you obtain for this visit?
b. What additional history would you obtain from the family that is significant to A.J.’s
situation
c. Practice using clinical reasoning and list possible diagnoses for A.J. based on the
subjective information provided
3. The SOAP note must include
i. Medical Diagnosis, 2 primary
1. Provide pathophysiology/Rationale/Plan (1 paragraph each)
2. ICD 10 code
ii. Differential diagnosis, 3-5 Differentials
1. Provide pathophysiology/Rationale/plan (1 paragraph each)
2. ICD 10 code
iii. Health maintenance/risk profile (if appropriate for the visit type)
iv. Pertinent positives (2 for each diagnosis, Primary and differential)
v. Pertinent negatives (2 for each diagnosis, Primary and differential)
b. Reference list (you should be researching your diagnosis, so 2 references are expected)
c. APA format
AM. is a 3-year-old female, in daycare   AM was in her normal state of health until 3 days ago
when she came home from daycare with a mild runny nose.  Her mother notes that over the
past 3 days the nasal drainage has increased, she has developed a cough, and sore throat, her
voice has changed, and last night she had a low-grade fever (tactile) when she came home from 

day care.  During the night she woke with up crying and hot, mom noted that her temperature
was 103.1 (taken under her arm) and she gave her Motrin (7 ml), and she was restless but went
back to sleep.  This morning the child woke up later than normal, has not had her normal
energy, has had about 2 ounces of milk, no food intake today, she is irritable and just wants to
be held.  Nasal drainage stated as clear but today was yellow and thick, she is needing help
blowing her nose, her nose is red and irritated, and when mom tried to wipe her nose the child
deflects and runs to the chair in the clinic.
Mom called the clinic this morning for a sick visit.  The temperature came down some after the
Motrin, but the child feels hot again at time of visit.  No vomiting or diarrhea with these
symptoms. No rash
AM was the first child born to this couple, she was a term birth, and since the family has had a
set of twins who were premature and required extensive NICU time (and just last week the
second infant came home with a g-tube and oxygen).  The mom is very concerned about the
infant who is home with her mother but is the first time she has left the infants.  She is anxious
to get a prescription and get out of the clinic today.  AM has been in daycare since she was 6
months, but in the past month had to move to a new day care (one that will eventually take all 3
children in the family), since the day care move mom has noted regression, more baby talk, she
bit someone recently at school.
AM has is up to date per the mom on her immunizations (for her age), has never been
hospitalized, no surgeries, does not take medications routinely, and has no allergies. AM was
seen in clinic 2 months ago for her 3-year-old well child and has had routine well exams since
birth in this clinic and intermittent sick concerns, mainly respiratory in nature, and one visit for a
fall.  
The family lives upstairs in a 2-bedroom apartment, it is tight right now with the twins, and mom
was working before she got pregnant, but is now having to stay home.  Dad works outside the
home in retail and is gone long hours.  No parental smoking.  Mom gives AM Tylenol and Motrin
if needed (but does not know the amount that she should give for AM’s weight).  AM eats a
toddler diet, drinks from a cup, speaks well with her friends and family, is normally playful, but
lately has had a harder time at this new school and has been very clingy and hard to get her to
go into the school in the mornings, she cries more recently.
AM’s mom and dad are married, with now the 3 children, no health issues are verbalized by
parents, no one else in the home has been sick.  AM’s mom says that her friend’s child who is in
the same class was given an antibiotic for the same symptoms last week, and she is better so
they just need a quick visit to get the antibiotic and she will need to get home soon to relieve
grand mom.