*****gastroenteritis ****
For this Assignment, you will work with a pediatric patient with “gastroenteritis “, and complete a Focused SOAP Note Template in which you will gather patient information, relevant diagnostic
and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this weeks Learning Resources as well as prior weeks resources, please refer to the Focused Note resources for guidance on writing Focused Notes.
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 and include their ICD-10 codes for the diagnosis. 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?
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