Doing a SOAP NOTE ,Discuss what questions you would ask the patient, what physical exam elements you would include, what further testing you would want to have performed, differential and working diagnosis, treatment plan, including inclusion of complementary and OTC therapy, referrals, and other team members needed to complete patient care.
1. Mr. Johnson has brought in his 3-year-old daughter Clara to be seen for vomiting and diarrhea for 2 days. He states that last night she vomited 3 times. This morning she vomited her breakfast of pancakes and sausage.
What more does the APRN need to know about Clara’s symptoms?
What should the APRN look for in the physical examination?
What type of anticipatory guidance should the APRN give Clara’s father?
