THIS IS A SOAP NOTE FORMAT: 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.
2. Sara is a 14-year-old brought into the clinic for an “annoying cough” for the past 4 weeks. The cough is worse at night, but is present during the day as well. Her mother reports no fever and no other symptoms, but states that Sara appears a little tired because she is not able to sleep well at night due to her coughing. No one else in the family has had a cough.
What more does the APRN need to know about Sara’s condition?
What should the APRN focus on during the physical examination?
What tests might the APRN order and/or anticipatory guidance regarding Sara’s condition?