If positive, the patient contains more fluid than a day ago. The remainder of the exam should be directed towards specific systems of concern. The Assessment and Plan section of the pediatric SOAP note are combined. This section should begin with a short paragraph restating the patient's reason for being in the hospital, information about their current status, and any general comment regarding the overall plan. In separate paragraphs, each system is evaluated and a plan is formulated.
Mother reports pt more active last night than earlier in the day, less irritable.
Tolerating pedialyte well in smaller than usual volumes. TMs translucent with good landmarks. RRR, nl S1 and S2, no mm. CFT less than 2 seconds. Based on positive rotavirus antigen assay, presumptive rotaviral gastroenteritis.