What would you include in subjective portion

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Annabelle is a 9 year old who comes with her mother today. Her mother states that Annabelle started out with a "runny nose" 3 days ago and then last night woke up during the night complaining of pain in her right ear. Mom took her temperature and it was 99.4 degrees oral. She gave her Tylenol and it came down to 98.0 degrees. Mom is concerned because Annabelle's temperature typically runs 97.0 degrees and she tells you "For Annabelle, 99.4 degrees is a high fever". Mom tells you that Annabelle is drinking well but does not want to eat. She has had a couple of loose stools this morning but no blood in her stools.

Currently, her vital signs are 99.1 oral, AHR 110, RR 18. She looks like she doesn't feel good and is sitting quietly with a frown.

When writing a soap note, What would you include in the subjective portion? Objective portion? Assessment portion? and Plan?

Reference no: EM133914051

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