NR509_Week_6_SOAP_Note.
S: Subjective
Information the patient or patient representative told you.
Initials: DR
Age: 8 years old
Gender: Male
... [Show More] Height: 4’2”
Weight: 90lbs
BP: 120/91
HR: 100
RR: 28
FVC: 3.91
FEV1: 3.15
FEV1/FVC: 80.5%
Temp: 37.2C
SPO2: 96%
Pain (1-10): 3
Allergies
Medication: NKDA
Food: No known food allergies
Environment: No known environmental allergies
History of Present Illness (HPI)
Chief Complaint (CC): Cough
Onset: 5 days ago
Location: Chest
Duration: Frequent (every couple of minutes without trigger noted)
Characteristics: Wet, productive with clear sputum
Aggravating Factors: Unknown triggers
Relieving Factors: Cough medicine alleviated the cough for a short amount of time
Treatment: Cough syrup today
Current Medications
Medication Dosage Frequency Length of Time Used Reason for Use
Kids Multivitamin Gummies Recommended dosing Daily Unknown Health maintenance
Cough Syrup Recommended dosing PRN Unknown Cough treatment
Past Medical History (PMHx)—
Danny is an 8-year-old male that denies any history of allergies to medications, foods, seasonal, latex or environmental agents. He reports having frequent colds and being diagnosed with pneumonia last year. He takes a daily dose of children’s multivitamin gummies as well as PRN doses of cough syrup to treat episodes of coughing. He reports that his immunizations are up to date and denies any other history of major illnesses (including asthma), hospitalizations, or surgeries.
Social History (Soc Hx)—
Danny is a 3rd grade student with a reported history of missing school for two weeks last year due to pneumonia. He lives with his mother and father and is cared for by his grandmother while his parents are working. English is the primary language spoken in the home with Spanish as an alternate language utilized.
Family History (Fam Hx)—
Danny’s mother has type II diabetes, hypertension, hypercholesterolemia, spinal stenosis, and is obese
Danny’s father is a smoker (cigars), and has hypertension, hypercholesterolemia, as well as a childhood history of asthma
Danny’s grandparent’s history:
Maternal—
Grandmother: type II diabetes and hypertension
Grandfather: Smoker and eczema
Paternal—
Grandmother: died in a car accident at 52 years of age
Grandfather: No known history
Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis
Constitutional
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
x Fatigue “kind of tired”
Weakness Denies
Fever/Chills Denies
Weight Changes Denies
Trouble Sleeping Denies
Night Sweats Denies
Other Denies
Skin
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Itching
Rashes
Nail
Skin Color
Other
HEENT
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Diplopia Denies
Eye Pain Denies
Eye redness Denies
Vision changes Denies
Photophobia Denies
Eye discharge Denies
Eye discharge Denies
x Earache x2days, right ear
Tinnitus Denies
Vertigo Denies
Hearing Changes Denies
Hoarseness Denies
x Sore Throat Reports “a little” pain and soreness
x Congestion “my cough seems kind of wet and gurgly”
x Rhinorrhea “my nose always runs a little, but it is worse since the cough started”
Other Denies
Respiratory
If patient denies all symptoms for this system, check here:
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
x Cough Frequent coughing without much relief from cough syrup
Hemoptysis Denies
Dyspnea Denies
Dyspnea Denies
Pain on Inspiration Denies
Other Denies
Neuro patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Syncope or Lightheadedness
Headache
Numbness
Tingling
Sensation Changes RUE
LUE
RLE
LLE
Speech Deficits
Other
Cardiac and Peripheral Vascular
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Chest pain
SOB
Exercise Intolerance
Orthopnea
Edema
Murmurs
Palpitations
Faintness
Occlusions
Claudications
PND
Other
MSK
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Pain
Stiffness
Crepitus
Limited ROM RUE
LUE
RLE
LLE
Redness
Misalignment
Other
GI
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Nausea/Vomiting
Dysphasia
Diarrhea
Appetite Change
Heartburn
Blood in Stool
Abdominal Pain
Excessive Flatus
Food Intolerance
Rectal Bleeding
Other
GU
If patient denies all symptoms for this system, check here: Denies all symptom
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Urgency
Dysuria
Burning
Hematuria
Polyuria
Nocturia
Incontinence
Other
PSYCH
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Stress
Anxiety
Depression
Suicidal/Homicidal Ideation
Memory Deficits
Mood Changes
Trouble Concentrating
Other:
GYN
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Rash
Discharge
Itching
Irregular Menses
Dysmenorrhea
Foul Odor
Amenorrhea
LMP
Contraception
Other:
Hematology/Lymphatics
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Anemia
Easy bruising/bleeding
Past Transfusions
Enlarged/tender lymph node(s)
Blood or lymph disorder
Other:
Endocrine
If patient denies all symptoms for this system, check here: Denies all symptoms
Check the box next to each reported symptom and provide additional details.
Check if Positive Symptom Details
Abnormal growth
Increased appetite
Increased thirst
Thyroid disorder
Heat/cold intolerance
Excessive sweating
Diabetes
Other:
O: Objective
Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings.
Body System Positive Findings Negative Findings
General Patient is AAOx4, well groomed, interactive and cooperative, and communicates appropriately based on age and educational status.
Skin Skin pink, warm, dry, and intact. There is no tenting. Hair is evenly distributed.
HEENT **For abnormal findings see bolded sections of the assessment in the next column** Face and head are normocephalic and symmetrical.
Inspection
Bilateral eyes/orbital area:
• No visible abnormalities
• Sclera—white
• Conjunctiva—pink/moist
• Conjunctival discharge—N/A
Bilateral nares:
• No visible abnormalities
• Pink and patent with clear drainage
Ears:
• Right auditory canal
o Erythemic
• Right tympanic membrane
o Erythemic
o No other visible abnormalities
o Cone of light 5:00
• Discharge
o None
• Left auditory canal
o Pink
• Left tympanic membrane
o Pearly gray
o No visible abnormalities
o Cone of light 7:00
• Discharge
o None
Mouth and throat:
• Oral mucosa
o Pink and moist
• Tonsils
o Erythemic
• Posterior oropharynx
o Erythemic
o Cobblestoning
• Post nasal drip
o None
Neck:
• Symmetrical
o No abnormalities
Chest:
• Symmetrical
o No abnormalities
Palpated
Sinuses:
• Frontal
o No tenderness
• Maxillary
o No tenderness
Lymph nodes:
• Cervical
o Palpable nodes on the right side
• Supraclavicular
o No palpable nodes
• Axillary
o No palpable nodes
Fremitus:
• Bilaterally symmetrical with expected fremitus
Auscultation
Breath sounds:
• Clear and present in all lung fields without evidence of adventitious sounds
Bronchoscopy:
• Negative
Heart sounds:
• S1 and S2 audible without any extra sounds
Percussion
• Chest wall
o All areas resonant without any areas of dullness
Respiratory Frequent cough throughout assessment encounter. Breath sounds:
• Clear and present in all lung fields without evidence of adventitious sounds
Bronchoscopy:
• Negative
Neuro Assessment not performed at this time
Cardiovascular Heart sounds:
• S1 and S2 audible without any extra sounds
Musculoskeletal Assessment not performed at this time Active ROM noted during assessment
Gastrointestinal Assessment not performed at this time Denies alterations to bowel patterns
Genitourinary Assessment not performed at this time Denies pain, burning, dribbling, or other alterations to urinary patterns
Psychiatric Assessment not performed at this time
Gynecological Assessment not performed at this time
Hematology/Lymphatic **For abnormal findings see bolded sections of the assessment in the next column**
Endocrine Assessment not performed at this time
A: Assessment
Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis from which the interventions on the Plan of Care (POC) is written.
.
Diagnosis ICD-10 Code Pertinent Findings
Upper Respiratory Infection (Common Cold) J00 Rhinitis and sore throat
Strep Throat J02.0 Acute sore throat
Suppurative otitis media, unspecified, right ear H66.41 Erythema to the right auditory canal and tympanic membrane
P: Plan
Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, select “None at this time” but do not leave any heading blank. No intervention is self-evident.
Diagnostics: List tests you will order this visit.
None at this time:
Test Rationale/Citation
Rapid Strep Test and Influenza testing Erythema and cobblestoning noted, rule out strep throat or influenza versus upper respiratory infection, pneumonia, or asthma
Throat Culture In case of negative rapid strep test, test for other viral and/or bacterial causes for symptoms
CBC Test for infectious processes that affect the blood counts
Chest Xray Rule out upper respiratory infection due to right ear pain, sore throat and runny nose, pneumonia due to history, and/or asthma due to familial history
Medication/Treatment: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent.
None at this time:
Continue previous meds:
Drug Dosage Length of Treatment Rationale/Citation
Children’s Multivitamin Gummies Recommended dosing Continued from history Continuing health maintenance practices
Delsym 15mg/5ml 5ml Q12 hours Start now PRN for frequent cough Treat frequent cough and allow patient to be less fatigued (Epocrates, 2019)
Augmentin 400mg/57mg per 5ml 20ml BID Start now and take for 10 days Treat otitis media, right ear (Epocrates, 2019)
Referral/Consults:
None at this time:
Referral/Consults: Rationale/Citation
No referral at this time
This otitis media is not a recurrent condition. If it were, I would refer to a pediatric ENT for evaluation and treatment
Education:
None at this time:
Education Rationale/Citation
-- Education regarding appropriate dosing of multivitamin related to patient reports that he sometimes takes extras “to be healthier”
--Education for all new medications, including the reason for the new medications, the risks of not completing prescribed medications, s/s of allergic reactions, when to stop taking, and what constitutes an emergency
--Cessation of familial smoking in the home to reduce occurrences of illness in pediatric patient
--Increasing water intake to encourage the resolution of cough and otitis media
Follow-Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere.
None at this time:
Follow-Up Rationale/Citation
Return to clinic in 1 week, or sooner if symptoms do not improve
Routine follow up to ensure condition is improving
Seek emergency care if you develop shortness of breath, hemoptysis, sudden high fevers which are resistant to OTC treatments, allergic reaction, or altered mental status These changes in condition could indicate an emergent situation
References (Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting.)
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