FNP 592 Week 3 Clinical Documentation Template

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 SOAP NOTE Clinical Documentation Template

Ali Junayed

United States University

FNP 592

Student Name and clinical course:  Ali Junayed

ID:

Client’s Initials*: XX           Age: 15    Race: Hispanic    Gender: Male Date of Birth: January 1, 2009 Insurance: No   Marital Status: Unmarried

Subjective:

CC: Coughing, wheezing and fever.

HPI: The chronic cough and high fever of a Hispanic male patient, who was 15 years old, prompted his referral to the clinic. According to the parent, the cough has been going on for five days and isn’t producing any mucus or other symptoms. An at-home thermometer verified the elevated temperature after three days. A parent reports that their child is unusually sleepy, has lost weight, and is generally more exhausted than usual. Nobody has been ill or been sick recently.

Past Medical History:

• Medical problem list: None
• Preventative care: Updated vaccinations.
• Surgeries: None

• Hospitalizations: None
• LMP, pregnancy status, menopause, etc. for women: Not applicable.

Allergies: NKDA 

Medications: None

Family History: No significantly contributing family history.

Social History: The young man resides with his parents and two younger siblings; he is a student. There has been no observation of any substance usage, smoking, or exposure to drugs.

ROS

CONSTITUTIONAL: Positive for weight loss, fatigue and fever.

HEENT: Negative for blurred vision,  sinus congestion, earache, rhinorrhea, double vision, and sore

throat. 

NECK: No lymphadenopathy.

RESPIRATORY: No significant changes in wheezing, shortness of breath, or DOE. The cough test results are positive.

CARDIAC: Chest discomfort is negative. Denies experiencing dizziness or palpitations.

GASTROINTESTINAL: Positive for reduced hunger, negative for excessive gas, belching, and early satiety. denies experiencing stomach pain, nausea, vomiting, diarrhoea, or constipation.

BREAST: There is no bulk, no gynecomastia.

GENITOURINARY: Disavows urgency, frequency, dysuria, and hematuria.

EXTREMITIES: Disavows loss of feeling and peripheral oedema.

SKIN: Reject any rash.

MUSCULOSKELETAL: Disavows joint, muscle, and bone pain.

NEUROLOGIC: Not present with headaches, seizures, syncope, light-headedness, tingling, or numbness.

PSYCHIATRIC: Adverse to sadness and anxiety.

 Objective

Vital Signs:   HR – 72 bpm    BP – 135/76      Temp- 101.1 RR-22       SpO2- 98%           Pain- 7.5/10

Height-72 inches     Weight- 189 lbs      BMI- 25.63

Labs, radiology, or other pertinent studies: Chest X-ray

Physical Exam

CONSTITUTIONAL: Appears to be the claimed age, well-developed, well nourished.

HEENT: A standard, non-traumatic head shape. There is no runny nose. The sinuses are not sore. Moist mucous membranes. There is no redness, swelling, or discharge from the oropharynx. A supple, symmetrical neck with a midline trachea. Lymphadenopathy is not detectable.

RESPIRATORY: Clear when auscultated. Proper ventilation. No chest tightness, rales, or wheezing.

CARDIAC: Regular beats per minute. Classical S1 and S2. None of the S3 or S4 varieties. Not a single mutter, twitch, or gallop.

GASTROINTESTINAL: Gentle, flat, painless. There is no evidence of hepatosplenomegaly.

EXTREMITIES: Absence of peripheral oedema, swelling, pain, or discolouration. 

SKIN: Normal.

MSK: Range of motion and strength are relatively unaffected and balanced.

NEUROLOGIC: Generally speaking, the ability to feel mild touch is unaffected. 

PSYCHIATRIC: Suitable disposition and emotional balance.

Assessment

Differentials:

Pneumonia: One possible diagnosis is pneumonia when fever and other respiratory symptoms are present (Mayo Clinic, 2020). Despite the lack of specific lung abnormalities seen during the patient’s physical exam, a chest X-ray would be necessary to evaluate any further changes in symptoms.

Pertussis: A plausible differential diagnosis might be pertussis, given the lack of temperature and prolonged cough. A polymerase chain reaction test may be performed if the persistent cough is suspected of pertussis, even when the distinctive “whooping” cough is absent (Lauria & Zabbo, 2019).

Diagnosis: 

Acute Bronchitis: We have diagnosed acute bronchitis. Acute bronchitis is the most probable diagnosis in this patient’s case due to the patient’s history of a prolonged cough, fever, and absence of specific abnormalities on physical examination. According to Singh et al. (2023), viruses usually cause these instances, and they often go away on their own. Supportive care measures may be used as part of a treatment strategy, such as promoting rest, increasing fluid intake, and reducing temperature.

Plan

Diagnostics:

1. A chest X-ray may help rule out pneumonia.
2. We can rule out pertussis with a PCR test.
3. A respiratory viral panel is performed to determine which viruses are causing these symptoms.
4. CBC

Treatment:

1. First, the patient should have enough fluids and rest, as advised by the doctor.
2. Take acetaminophen or ibuprofen, two over-the-counter pain relievers, as recommended for your age to alleviate fever and discomfort.
3. He will inform his parents about the symptoms of acute bronchitis, how it progresses, and that they should return if they worsen or do not go away.

Education

The need to get enough rest, stay hydrated, and properly administer medications to reduce fever will be driven home to the patient’s parent(s). They will be advised to monitor any worsening symptoms and seek immediate medical attention if they notice any changes.

Follow Up

Recommend that the patient return for a re-evaluation in four weeks. 

References

Lauria, A. M., & Zabbo, C. P. (2019, June 3). Pertussis (Whooping Cough). Nih.gov; Stat-pearls publishing. https://www.ncbi.nlm.nih.gov/books/NBK519008/

Mayo Clinic. (2020, June 13). Pneumonia. Mayo clinic. https://www.mayoclinic.org/diseases-conditions/pneumonia/symptoms-causes/syc-20354204

Singh, A., Avula, A., & Zahn, E. (2023). Acute Bronchitis. Pub-med; Stat-pearls publishing. https://www.ncbi.nlm.nih.gov/books/NBK448067/#:~:text=Acute%20bronchitis%20is%20caused%20by

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