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Mini SOAP-notes

 

Student’s Name

Institutional Affiliation

Course Name and Number

Instructor

Due Date

 

 

Mini SOAP-notes

  1. 8500; G93.7

S: Pt-9y/o male; severe fatigue x 5 days, rapid breathing

O: Confused (Non-oriented x3); low blood sugar

A: Reye’s syndrome

P: Supportive care

  1. 2000F; L01.00

S; 3-month old female, red itchy sores, 1 week, leak clear fluid

O: HR 68 BP 122/71. Ht 5’5, Wt 132 lb. BMI 21.5; Red sores around the nose

A: Impetigo

P: Topical penicillin cream 3 times a day

  1. 40001F; F53.0

S:  29 y/o woman, normal delivery 3 days ago/ mood swings/ depression

O: Stable vitals, restless, irritable, unmotivated, difficulty sleeping

A: post-partum depression

P: Counseling, bupropion 100mg oral twice a day

  1. 81099; O20.8

S:  Pt-24 y/o female, pain in the vagina x 3 days; 1 week pregnant; 2 abortions

O: BP 125/85; vaginal bleeding/bright red

A: Sub-chorionic bleeding

P: 10mg dydrogesterone daily until week 12 of pregnancy, regular check ups

  1. 80047; Q24.9

S:  33 y/o woman, first trimester; increased heart beat x 3 days

O: HR 68 BP 122/71. BMI 21.5; High cholesterol

A: Congenital heart disease

P: Adenosine 50 mcg/kg IV push increased by 50 mcg/kg q2 min until sinus rhythm. Max: 250 mcg/kg; Dietary recommendations

  1. ICD 10: G43.90

S: Headache present, 7/10 in pain severity, nausea, vomiting, sensitivity to light.

O: Vitals: Ht. 5’0, Wt. 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, Pox 99%

A: headache, subarachnoid hemorrhage.

P: Labs: CBC, CMP (normal range), UA (No glucose, ketones, RBCs in urine. CT ordered STAT).

  1. ICD 10: R10.11

S: Pain in the upper right quadrant of her abdomen, nausea.

O: Vitals: BP 125/85 P 70 bpm R 16 breaths T 99.1°F.

A: DX: abdominal pain, suggested of gall stone disease.

P: Labs: CBC and liver function test. Stay hydrated. Limit the  physical activities.

  1. ICD 10: Z01.30

S: Blood pressure is 140/92, previous visit 154/100.

O: Vitals: Temp: 97.7, P: 44, BP: 140/90, RR: 18, W: 161, H: 5.9, BMI: 23.8

A: DX: Hypertension. White coat syndrome.

P: CMP, lipid panel, uric acid level, UA, and EKG.

  1. ICD 10: Z71.2; E78.0

S: Cholesterol labs high.

O: Vitals: HR 68 BP 122/71. Ht 5’5, Wt 132 lb. BMI 21.5.

A: Hypercholesterolemia >200

P: Move on with regimen atorvastatin, RTC in 3 months.

  1. ICD 10: R05, R09.89

S:  Cough, body aches, headache.

O: Vitals: BP: 132/72, Pulse: 82, Temp: 98.8,

A: Cough and chest congestion.

P: Chest x-ray ordered STAT to rule out pneumonia.

  1. ICD 10: J44.1

S: Shortness of breath and feels tired.

O: Vitals: BP: 144/78, Pulse: 92, Diminished breath sounds

A: DX: COPD history of obesity, DVT.

P: RX: evaluate the COPD status by spirometry, weight loss, physical activities daily.

  1. ICD 10: M06.89

S: pain throbbing throughout the shoulders, elbows, wrist, hip, and knee.

O: BP: 140/90 abnormal; HR: 86 bpm; RR: 18; T: 98.8°F, Height: 5’6; Wt: 165 lbs. BMI: 26.6.

A: Rheumatoid Arthritis - critical stage. Severe pain and discomfort in joints.

P: Ordered labs: Iron test, thyroid function test, and RA factor test.

  1. ICD 10: R10.9

S: Abdominal pain, no fever.

O: Vitals: H: 5’10” W: 160lbs Pulse: 72 RR 16 BP 126/78 Temp: 99.0 pain level 6 out of 10.

A: Unspecified abdominal pain.

 P: Metamucil for constipation.

  1. ICD 10: A59.01

S: pain during sexual intercourse. No history of STIs.

O: Vitals: Temp: 98.6, BP: 122/64, HR: 72, RR: 18 W: 142, H: 5’6, BMI: 23.9.

A: DX: Trichomonas vaginalis.

P: RX: Metronidazole 500mg PO BID x 7 days.

  1.  ICD 10: E78.5

S: Lipids test.

O: Vitals: BP: 140/98 Pulse: 89 RR: 21 Temp: 98.5 H: 6’1 W: 196.

A: Hyperlipidemia.

 P: Labs: Fasting lipid test, Stop simvastatin.

  1. ICD 10: Z32.00

S: Pregnancy test.

O: T 98.6 HR 60 RR 18 BP 112/74 H: 4’6, W: 103, BMI: 24.8

A: Urine HCG, positive: Pregnant

P: Further evaluation and treatment.

  1.  ICD 10: F41.9; Z86.59

S: Increased            anxiety.

O: Vitals: Temp: 97.7 Pulse: 68 RR: 16 BP: 126/80.

A: Anxiety and depression.

P: Increase Celexa to 60mg daily.

  1.  ICD 10: F43.10

S: Pregnancy test.

O: T 98.6 HR 60 RR 18 BP 112/74 H: 4’6, W: 103, BMI: 24.8

A: Urine HCG, positive: Pregnant.

P: Further evaluation and treatment.

  1. ICD 10: N73.9

S:  Abdominal pain, cramping, slight fever, and pain when urinating.

O: BP: 104/72, HR 84, RR: 18, Temp: 99.8, W: 132, H: 5’6, BMI: 21.3.

A: diagnosis: Pregnancy, Vaginitis, and UTI.

P: Ceftriaxone 250 mg intramuscularly once, plus doxycycline 100 mg

  1. ICD 10: N63.0, R92.8

S: Non-painful lumps to her breasts, high blood pressure 3 years ago.

O: Temp: 98.3, H: 5’2, W: 144, BMI: 26.3 (overweight). BP: 138/80, Pulse: 73, RR: 16.

A: Bilateral palpable breast mass.

P: breast biopsy. No medication at this time.

  1. Patient ID: Term AGA male

S: did well O/N

O: BFx 11, void, VSS, stool x 5 mec,  algo passed B, TB at 24 hours after birth; wt- 3400g ( 4% down  from birth weight); appearing well, awake and alert.

A: Mild jaundice and TB, low risk on Bhutani graph

P:  Follow clinical recommendations for jaundice; repeat TB examination if condition worsens; routine pediatric care.

  1. Patient ID: 14 hour old term newborn

S: 39+ 3 weeks by NSVD, baby received y PPV for 28 seconds to improve tone

O: baby doing 12 hours after birth, breastfed x3, void and stool x 1 each, VSS. Wt.- 3550g, length 49 cm, OFC 33 cm, temp 36.6, HR 147, RR-50; gen well appearing, crying with exam

A: Term AGA with low first Apagar with R parietal caphalohematoma

P: anticipate spontaneous resolution of cephalohematoma; recommended BF class.

  1. Patient ID:  2 month old baby

S: Sore throat symptoms, persistent for 16 days; HPI- reports fever, rash, cough, swollen lymph nodes.

O: All systems negative except for the HPI; well developed, nourished. Vitals are stable

A: Acute pharyngitis

P: symptomatic treatments encourage fluid intake; Tylenol as needed; consider strep pharyngitis contagious until treated for 24 hrs.

  1. Patient ID: 24-day old newborn

S: CC- rash in the diaper area is worsening; healthy since discharge

O: 40 weeks birth, no past medical history, no medications, temp: 37.9, P-156, RR 45, BP;86/47, wt.-3410g; well appearing, alert and awake

A: Vesicular diaper rash likely caused by herpes simplex or SSSS.

P: Evaluate and treat for the possible causes (HSV, SSSS, or bullous impetigo)

  1. Patient ID:  5 month old male

S: sharp epigastric pain x 3 days

O: Tender to light and deep palpation of epigastric region. No guarding or rebound, CVAT, organomegaly

A: gastroenteritis

P:  Ondansetron (Zofran) 8mg PO q8h prn; follow up with PMD

  1. Patient ID: 4 month old baby

S: itchy patches on shoulder & legs x 1 month

O: alert and oriented x3, 2 mm red rough keratoitc macules on shoulders and proximal legs

A: chronic hand eczema

P: Liquid nitrogen 10-second freeze for destruction of nine actinic keratosis; discuss follow-ups in 2-3 weeks

  1. Patient ID: 5 year old male

S: Lumpy stool x3 a week

O: Abdominal bloating

A: Constipation.

P: 50-300 mg PO once daily; advise on dietary considerations

  1. Patient ID:  4 year old female

S: Pleomorphic rash spreading to the rest of the body.

O: lesions have predominated central skin areas and proximal upper extremities.

A: Low grade fever; varicella.

P: routine use of acyclovir or valacyclovir.

  1. Patient ID:  8 month old baby

S: Baby is lethargic.

O: Rash inside the mouth.

A: Neonatal herpes.

P: start on 0 mg/kg IV q8hr for 21 days; continue breastfeeding.

  1. Patient ID:  29 year old woman

S: C-section/ premature membrane rupture

O: Hypotension (day 3 of onset); TSST-1 in vaginal discharge

A: septic shock with DIC

P: Low-dose hydrocortisone an IV fluids; insulin for blood stability

  1. Patient ID:  2-day old baby

S:  normal delivery; not well on O/N

O: Cloudy white appearance in the eyes

A: Congenital rubella

P: close monitoring; treatment unavailable

  1. Scenario

S: Pt has severe fever, intermittent cramping

O: pitting edema, oral temp @ 101.5, rapid strep +

A: Strep pharyngitis

P: Amoxil 500 mg x 7 days; Ibuprofen 600mg

  1. Scenario

S: Moderate lochia, no BM yet

O: Ext- +1 pitting edema, neg calf pain; minimal edema

A: Rubella immune, Breastfeeding

P: Rx: Ibuprofen 600mg; Tylenol 1000mg PO q 6

  1. Scenario

S: ambulating PRN, denies N/V, no clots

O: CTAB, Fundus firm, neg calf pain

A: s /p NSVD doing OK; Pain well controlled

P: Tylenol 1000mg PO q 6; RTC in 3 days

  1. Scenario

S: shoulder dystocia; weight gain

O: Intrauterine pregnancy; no anomalies

A:  Baseline 140’s; Contractions @q 4-5 min

P: Admit to the L& D; fetal monitoring

  1. Scenario

S: Breastfeeding; Contraceptive plan; vaginal bleeding

O: skin intact; uterine fundus below umbilicus; No Edema

A:  tolerating diet; need rubella vaccine

P: Give rubella vaccine; discharge if pt if uncomplicated for 24-48

  1. Scenario

S: Nausea; vomiting; Pain

O: low BP; Breast engorged

A:  adequate urine output; Out of bed

P: Pain medications; Discharge IV

  1. Scenario

S: Regular menses (q 28 days); Minimal rev 5/1/2017 dysmenorrhea.

O: skin changes; multiparous cervix; uterus small

A:  Pelvic pain not responding to medical intervention

P: Diagnostic laparoscopy

  1. Scenario

S: Pt feels CTX; plans epidural

O: CTX palpate

A:  Edema; pre-eclampsia

P: Pitocin augmentation; place internal monitors

  1. Scenario

S: Sexually active; new partners; history of DVT

O: Normal Urine hCG test result

A:  IUD, oral contraceptives; nuvaring option

P: Start folic acid 800 mcg; Education/Counseling

  1. Scenario

S: Pt requests contraception; well-nourished; no distress

O: Urine HCG negative; alert and oriented

A:  no absolute contraindications

P: Discuss benefit of the method; give the preferred option

  1. Scenario

S: Pt admitted because of vaginal bleeding; bleeding began the same day

O: Blood type O+; VDRL; Allergic to Penicillin

A:  Hemodynamically stable; vaginal bleeding

P: Hospitalize patient; Assess fetal status and maternal status cervical examination; Ultrasonography

  1. Scenario

S: Pt with irregular periods; unsure LMP; unintended pregnancy; first antepartum clinic

O: Blood type O+; BP 118/68; RR 19; normocephalic head

A:  Mild Nausea; history of diabetes

P: Pap smear; fetal genetic screening; cystic fibrosis screening

  1. Scenario

S: c/o intermittent; cramping; pain rating 4/10.

O: SVE 4/61/-3; IUPC placement; A/P: @ 38w3d.

A:  Chronic pain and cramping.

P: Fetal Monitoring; labor support; Epidural PRN; liquid diet.

  1. Scenario

S: Pain rating 3/10; + flatus, intermittent cramping

O: ABD non-tender; Laceration clean; +2 DTRs

A:  PPD#2; Pain well controlled

P: Ibuprofen 600mg q 6 hours; Pelvic rest

  1. Scenario

S: Pt feel body; tired; cannot concentrate 

O: T98.6; BP135/94; TOCO – q min; Abd: soft

A:  PPD#2; s/p elective R/LTCS

P: Advance to regular diet; breast/bottle feeding; Routine post-op support and care

  1. Scenario

S: Pt c/o fever, sore throat × 3 days

O:  Temp-99.6, BP-100/68, Very erythematous, Rapid strep group a +

A: Tonsilitis

P:  RX: Bicillin L-A 1,200,000 units/2ml IM syringe Inject 1.2ml by intramuscular.

Return if pain persists, do not go to school for 24 hrs, follow up.

  1. Scenario

S: Pt c/o ear pain × 3 days

O: Temp: 103.2, bulging, Right tympanic membrane, diminished light reflex

A: Acute Otitis Media (AOM)

P: Amoxil (90mg) PO BID × 10 days: Tylenol suspension (160mg/5ml) 4-6hrs; Benzocaine 20%, optic drops 4 drops 1-2 hrs: follow up

  1. Scenario

S: Pt c/o coughing × 7 days

O: Weight 64 pounds, Temp 88.7, dry cough, clear conjunctiva, mouth and nose

A: allergic cough

P: Normal examination, appointment 3 days from now, if fever develops, mom should call.

  1. Scenario

S: Pt c/o halitosis, sore throat × 2 days, congestion, coryza

O: temp 97.4, 91 pounds, slight nasal congestion, red tonsils, clear tympanic membranes

A: allergic rhinitis

P: Penicillin 250 mg p.o. t.i.d × 10 days: change toothbrush after 4 days

  1. Scenario

S: Pt c/o seen for pneumonia few weeks treated with azithromycin, wheezing 2 days ago, responded well to nebulized albuterol, significant congestion.

O: Temp 98.4,454 pounds, clear nasal discharge, good breathing sounds

A: reactive airways disease but responds well to nebulized albuterol

P: nebulizer with tubing. Albuterol solution 1 drop after every 5 hrs. Follow up in a week.

  1. Scenario

S: Pt c/o itchy rash, given Benadryl

O: no distress, active and awake, rush on the trunk, slightly erythematous papules

A: viral, allergic rash

P: rapid step test mange using Benadryl or Zyrtec, anti-itch cream

  1. Scenario

S: Pt c/o, sore throat, runny nose, cough congestion × 5 days

O: temp 99.3, 80 pounds, clear conjunctivae, clear tympanic membranes. Pupils reactive to light, negative rapid step screen

A: viral nasopharyngitis.

P:  send for culture and s=further tests. Supportive care measures reviewed. Follow up.

  1. Scenario

S: Pt c/o watery eyes × 4 days, green discharge

O: Temp 98.7. 83 pounds, watery eyes, pink and moist oropharynx

A: Mild conjunctivitis.

P: amoxicillin, 80 mg/kg/day, × 10 days discuss supportive measures with parent.

  1. Scenario

S: Pt c/o Headache, difficulty concentrating in class, patient fell and hit the back of his head while playing basketball yesterday

O: temp 98.7, BP 119/80,HR 73 RR 16, oblong hematoma on scalp above the base of skull

A: concussion without loss of consciousness, tension headache

P:OTC  Tylenol 500mg 4-6 hrs , no TV, Computer, no playing basketball for  the next 24 hrs return after 2 days for reevaluation

  1. Scenario

S: Pt c/o fever, congestion, decreased appetite, runny nose

O: temp 97.8, pulse 100, respiratory rate,23 weigh 8.5 kg, Erythematous confluent area with satellite lesions, moist mucus membranes

A: Prolonged viral upper respiratory infection

P: Tylenol or ibuprofen as needed for fever or pain. Discussed warning signs

  1. Scenario

S: Pt c/ Cough 2 weeks, cold last week, some fever

O: Ox 98%, temp 99.7, pulse, 100 weight 16 kgs, labored respiratory rate of 28, wet cough

A: Pneumonia

P: Amoxil 400mg/5ml 1 ½ tsp, PO, BID × 10 Days, encouraged a lot of fluids, return if cough is persistent

  1. Scenario

S: Pt c/o 3 BMS last week, brown, round and hard, a lot of straining while passing BM, patient does not take fruits and vegetables

O: pulse 93, temp 96.7, weight 15.7 kgs, no palpable masses

A: functional constipation

P polyethylene glycol 1g/kg/day (maximum 16g/day). Increase water, fruit, vegetable intake.

Miralax in a glass of water per day until the stool achieves a soft consistency.

  1. Scenario

S: Pt c/o well child checkup. Happy and active, well groomed.

O: Temp 98.2, pulse 65, BP 108/64, Ox 100%, BMI 21.67, normal ears, normal female, clear lungs

A: the child has achieved all the milestones appropriately and according to her age

P: Educated the mother on injury prevention, balanced diet, and answered all her questions. Appropriate handouts issued to mum

  1. Scenario

S: Pt c/o cough, runny nose, low temperature, sneezing, child given albuterol which helped with the coughing

O: temp 98.3, pulse 111, bp not obtained, eyes slanting towards edge of face, flat nasal bridge, clear nasal discharge, pink and moist m/m, Asthma exacerbation and OM, course wheezing

A: Asthma exacerbation

P: Orapred 15mg/15ml 4ml each day. Use albuterol for cough and Nasonex spray at night only, Dosage explained to mum

  1. Scenario

S: Pt c/o diarrhea 4 days, emesis 3 days, suspected food poisoning from chicken

O: BP 107/66, temp 99.6, pulse 111, 2 weight, 20 kgs, benign abdomen, white blood cell 5.4 with 68 segs, 16 lymph 12 monos, platelets 200.

A: viral gastroenteritis

P: stay away from milk products, educate on BRAT Diet, and follow up

  1. Cervical Dysplasia

S: irregular menstrual cycle, pelvic pain. No swelling, pain, glands

O: Ht. 5’0, Wt. 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, Pox 99%

A: Polycystic ovary syndrome, pelvic inflammatory disease, uterine fibroids

P: Encourage continuous OBGYN visit at least once a year across the lifespan to detect the risk                      

  1. Polycystic Ovarian Syndrome

S: infrequent or prolonged menstrual periods

O: Temp: 97.7, P: 44, BP: 140/90, RR: 18, W: 161, H: 5.9, BMI: 23.8

A: high androgen levels, irregular periods, and cysts in the ovaries

P: Frequent clinics

  1. Uterine Fibroids

S: abnormal menstrual bleeding

0: BP 125/85 P 70 bpm R 16 breaths T 99.1°F.

A: blood count (CBC) to determine Anaemia

P: Go-nadotropin-releasing hormone (GnRH) agonists

  1. Urinary Incontinence

S: stress incontinence, overflow incontinence, overactive bladder

O: BP: 132/72, Pulse: 82, Temp: 98.8,

A: loss of bladder control

P: Practice pelvic floor exercises

  1. Pelvic Pain

S: menstrual cramps

O: Ht 5’5, Wt 132 lb. BMI 21.5.

A: ectopic pregnancy

P: consultant for further specialist investigations

  1. Dysmenorrhea 

S: pain with menstrual cramps

O: BP: 130/70, Pulse: 81, Temp: 98.8,

A: Cannot control the bladder

P:More exercises

  1. Vulvodynia

S: pain at the introits and vulva.

O: BP: 144/78, Pulse: 92, Presence of blood in the vulva

A: Irritation of the nerves surrounding the vulva

P: physical therapy with biofeedback

  1. Ovarian cysts

S: fluid in the ovary

O: BP: 140/90 abnormal; HR: 86 bpm; RR: 18; T: 98.8°F, Height: 5’6; Wt: 165 lbs.

A: Low estrogen levels

P: Loestrin pills

  1. UTI

S: A burning sensation when urinating

O: GI bacteria spread from the anus to the urethra

A: A suppressed immune system

P: Empty bladder after intercourse

  1. Pelvic inflammatory disease

S: painful sex, painful urination

O: High fever, HR: 86 bpm; RR: 18; T: 98.8°F

A: Foul-smelling vaginal discharge

P: Temporary abstinence

  1. Genital herpes

S: Pain and tenderness in genital areas

O: lymph glands swollen

A: headaches, body aches, and fever

P: Antiviral drugs

  1. Cervical insufficiency

S: sensation of pelvic pressure

O: Light vaginal bleeding/spotting, painful cervix

A: feeling pain in the vulva.

P: frequent body exercises

  1. Fibroma

S: Itchiness, occasional tenderness

O: : BP 125/85 P 70 bpm R 16 breaths T 99.1°F.

A: Headache, Nausea

P: Corticosteroid injections into the fibroma

  1. Gestational diabetes

S: Nausea, Constipation

O: Temp: 97.7, P: 44, BP: 200/90, RR: 25, W: 161, H: 5.9, BMI: 23.8

A: High blood sugar

P: Healthy diet

  1. Ovarian cancer

S: discomfort in your tummy or pelvic area.

O: BP 125/85 P 70 bpm R 16 breaths T 99.1°F.

A: Bloating

P: Regular checkups and therapies.

  1. Overactive bladder

S: Pain in urination

O: Temp: 97.7, P: 44, BP: 140/90, RR: 18, W: 161, H: 5.9, BMI: 23.8

A: Urinary canal infections

P: Drinking a lot of water

  1. Yeast infection

S: Vaginal yeast infections

O: Temp: 98.6, BP: 122/64, HR: 72, RR: 18 W: 142, H: 5’6, BMI: 23.9.

A: Pain in urination

P: Pelvic exercises and regular check up

  1. Preeclampsia

S: Changes in vision, severe headache

O: T 98.6 HR 60 RR 18 BP 112/74 H: 4’6, W: 103, BMI: 24.8

A: Decreased urine output

P: Drink a lot of water

  1. Preterm labor

S: Mild abdominal cramps

O: BP: 140/98 Pulse: 89 RR: 21 Temp: 98.5 H: 6’1 W: 196

A: Vaginal spotting

P: Avoid smoking

  1. Hepatitis B

S: Abdominal pain, Dark urine

O: BP: 104/72, HR 84, RR: 18, Temp: 99.8, W: 132, H: 5’6, BMI: 21.3

A: Headache

P: Avoid harmful drugs

  1. Febrile Seizure

S: Loss of consciousness

O: Temp: 98.3, H: 5’2, W: 144, BMI: 26.3 (overweight). BP: 138/80, Pulse: 73, RR: 16.

A: Legs and arm weakness

P: intravenous diazepam and lorazepam

  1. Jaundice

S: Yellow body fluids

O; BP: 104/72, HR 84, RR: 18, Temp: 99.8, W: 132, H: 5’6, BMI: 21.3

A: Obstruction of the bile duct

P: Removing the obstruction

  1. Hepatitis A

S: ever, malaise, loss of appetite, diarrhea

O: Temp: 98.3, H: 5’2, W: 144, BMI: 26.3 (overweight). BP: 138/80, Pulse: 73, RR: 16.

A: dark-colored urine

P: Drink plenty of water

  1. Head, foot , and mouth disease

S: Pain in the mouth and the feet

O: Temp: 98.6, BP: 122/64, HR: 72, RR: 18 W: 142, H: 5’6, BMI: 23.9.

A: Foot rot and infections in the mouth

P: Drink clean water and regular checkups, use anti-bacteria

  1. Sinusitis

S: Yellow discharge in the nose

O: Temp: 98.3, H: 5’2, W: 144, BMI: 26.3 (overweight). BP: 138/80, Pulse: 73, RR: 16.

A: Bad breath, cough

P: Mouth wash

  1. Bronchiolitis

S: Blockage chest and coughing

O: Temp: 98.6, BP: 122/64, HR: 72, RR: 18 W: 142, H: 5’6, BMI: 23.9.

A: Nasal discharge

P: supplemental oxygen, nasal suctioning.

  1. Fetal Alcohol Spectrum Disorders ( FASDs)

S: Headache

O: Ht. 5’0, Wt. 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, Pox 99%

A: Bloat

P: Avoid use of alcohol

  1. Diphtheria

S: Sore throat

O: BP 125/85 P 70 bpm R 16 breaths T 99.1°F.

A: Swollen glands in your neck, difficulty breathing and swallowing.

P: Antibiotics

  1. Measles

S: Sneezing, running nose

O: Ht. 5’0, Wt. 175 lbs., BMI 34.2, T 98.6 F, BP 132/70, P 108, RR 16, Pox 99%

A: small greyish-white spots in the mouth

P: Injection

  1. Mumps

S: fever, headache, muscle pains

O: Temp: 99, P: 44, BP: 140/90, RR: 18, W: 161, H: 5.9, BMI: 23.8

A: pain and swelling in the salivary glands

P: Take over-the-counter pain relievers, such as acetaminophen and ibuprofen, to bring down your fever.

  1. Croup

S: A runny nose, a stuffy nose, and slight cough

O: BP 125/85 P 70 bpm R 16 breaths T 99.1°F

A: Loss of the voice

P; Antibiotics

  1. Fifth disease

S: Stuffy and runny nose

O: BP: 132/72, Pulse: 82, Temp: 98.8,

A: Bright red cheeks

P: Drink warm water, antibiotics

  1. Pertussis

S: Rapid coughs followed by a high-pitched “whoop” sound.

O: HR 68 BP 122/71. Ht 5’5, Wt 132 lb. BMI 21.5.

A: Vomiting

P: Avoid cold drinks

  1. Strep throat

S: Difficulties in swallowing

O: Pulse: 82, Temp: 98.8

A: Sore throat

P: Use Strepsils

  1. Scarlet fever

S: Increased body temperatures

O: HR 68 BP 122/71. Ht 5’5, Wt 132 lb. BMI 21.5

A: Body fever

P: Antibiotics

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