WK 7 SOAP NOTE 2025

Case Study: With this patient in mind, address the following in a SOAP Note:( I HAVE INCLUDED A SAMPLE SOAP NOTE FOR REFERNECE ONLY ) A 3 y/o African American female who present with her mother with a complaint of coughing for a week. Mother reports that she has been coughing every night. She has also had a mild fever of 100.5 at home. Her mother has been using a decongestant/antihistamine syrup and albuterol syrup at home from her previous prescription. Initially the cough improved but it worsened over the last 3 days. She is noted to have morning sneezing and nasal congestion and she goes to pre-school where some of her classmates were noted to be sick. She has no know allergies and up to date with immunization. Previous medical condition is asthma that has been controlled by albuterol inhaler and Nebulizer as needed With this patient in mind, address the following in a SOAP Note: •Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies. •Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. •Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why? •Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan. •Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation? Reference Readings •Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier. ◦Chapter 31, “Respiratory Disorders” (pp. 708–738) •Chapter 40, “Genetic Disorders” (pp. 1032–1054) •Bradley, J. S., Byington, C. L., Shah, S. S., Alverson, B., Carter, E. R., Harrison, C., Swanson, J. T. (2011). The management of community-acquired pneumonia in infants and children older than 3 months of age: Clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clinical Infectious Diseases, 53(7), e25–e76. Retrieved from the Walden Library databases. •National Heart, Lung, and Blood Institute. (2007). Expert panel report 3 (EPR3): Guidelines for the diagnosis and management of asthma. Retrieved from http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm •Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis by Ralston, S.L., Lieberthal ,A.S., Meissner, H.C., Alverson, B.K., Baley, J.E., Gadomski ,A.M., Johnson, D.W., Light, M.J.,

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Dietary Reference Intakes (DRI) 200 words 2025

Complete the Interactive DRI on yourself. Go to http://fnic.nal.usda.gov/fnic/interactiveDRI/ Be prepared to answer the following questions: What are the three components of the DRI? Describe how RDA, AI, and UL influence health? After reviewing your results on the Interactive DRI, how well are you meeting the RDAs suggested? What two changes can you make to improve? You Entered: Female Age: 25 yrs Height: 5 ft. 2 in. Weight: 135 lbs. Active Not Pregnant or Lactating Results: Body Mass Index (BMI) is 24.9 Estimated Daily Caloric Needs: 2358 kcal/day • About BMI Each reference value refers to average daily nutrient intake ; day-to-day nutrient intakes may vary. Macronutrient Recommended Intake per day Carbohydrate 265 – 383 grams 1 Total Fiber 25 grams Protein 49 grams Fat 52 – 92 grams 2 Saturated fatty acids As low as possible while consuming a nutritionally adequate diet. Trans fatty acids As low as possible while consuming a nutritionally adequate diet. α-Linolenic Acid 1.1 grams 3 Linoleic Acid 12 grams 3 Dietary Cholesterol As low as possible while consuming a nutritionally adequate diet. Total Water* 2.7 Liters (about 11 cups) *Total water includes all water contained in food, beverages, and drinking water. Click on numbered footnote for more information. Each reference value refers to average daily nutrient intake ; day-to-day nutrient intakes may vary. Vitamin Recommended Intake per day Tolerable UL Intake per day Vitamin A 700 mcg 3,000 mcg 4 Vitamin C 75 mg 2,000 mg Vitamin D 15 mcg 100 mcg Vitamin B 6 1 mg 100 mg Vitamin E 15 mg 1,000 mg 5 Vitamin K 90 mcg ND Thiamin 1 mg ND Vitamin B 12 2 mcg ND Riboflavin 1 mg ND Folate 400 mcg 1,000 mcg 6 Niacin 14 mg 35 mg 7 Choline 425 mg 3,500 mg Pantothenic Acid 5 mg ND Biotin 30 mcg ND Carotenoids NA ND 8 Click individual vitamin for fact sheet. Click on numbered footnote for more information. Each reference value refers to average daily nutrient intake ; day-to-day nutrient intakes may vary. Mineral Recommended Intake per day Tolerable UL Intake per day Essential Calcium 1,000 mg 2,500 mg Chloride 2.3 g 3.6 g Chromium 25 mcg ND Copper 900 mcg 10,000 mcg Fluoride 3 mg 10 mg Iodine 150 mcg 1,100 mcg Iron 18 mg 45 mg Magnesium 310 mg 350 mg 9 Manganese 1.8 mg 11 mg Molybdenum 45 mcg 2,000 mcg Phosphorus 700 mg 4,000 mg Potassium 4.7 g ND Selenium 55 mcg 400 mcg Sodium 1.5 g 2.3 g Zinc 8 mg 40 mg Non-Essential Arsenic NA ND 10 Boron NA 20 mg Nickel NA 1 mg Silicon NA ND 11 Sulfate NA ND Vanadium NA 1.8 mg 12 Click individual mineral for fact sheet. Click on numbered footnote for more information.

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