Soap_Note_Week5_Rewrite.pdf - S CC Productive cough wheezing and labored breathing X 2 days HPI Established 10 month old male child who presents to

Soap_Note_Week5_Rewrite.pdf - S CC Productive cough...

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S: CC: Productive cough, wheezing, and labored breathing X 2 days. HPI: Established 10 month old male child who presents to clinic with the chief complaint (per mother report) of productive cough, wheezing, and labored breathing X 2 days. Unable to control symptoms with albuterol and breathing treatments. Mother denies fevers at home. Pt was seen in clinic care, given douneb treatment prior to arrival, and sent to clinic for further evaluation. PMH: Asthma (Diagnosed at 4 months old r/t multiple episodes of wheezing) Allergies: Seasonal Allergies (assumed, pt not old enough for allergy testing yet) Surgical: No surgeries. Current Medications: Zyrtec 2.5mg once a day before bed. Singular 4mg once a day. Flonase – 1 spray per nostril everyday. (Appropriate and successful in treating infants with allergic rhinitis with 3 or more episodes of wheezing that has been responsive to bronchodilators). Albuterol Inhaler PRN Q4-6 hours. Albuterol nebulizer treatments PRN Q4 hours for wheezing. (All of these medications were started prior to this visit). Vaccinations: Up to date on all vaccinations. Pt did receive both flu shots this season.
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