Focused SOAP Note Of Coughing Patient Assignment

Focused SOAP Note Of Coughing Patient Assignment

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Patient Information:
Initials: D.R.
Age: 11
Sex: Male
Race: Hispanic
S.
CC: “I have been sick and coughing a lot.”
HPI: Danny Rivera, a Hispanic boy who is 11 years old, presents to the clinic complaining of a cough that first manifested itself five days ago. He claims that the cough is more severe at night, which keeps him awake. He expresses overall tiredness since he has not been getting enough sleep. He has been experiencing soreness in his right ear as well as in his throat recently. He claims that his mother treated his cough with “purple syrup” this morning and gave him a spoonful of it. He states that his nose is always runny and that his cough is watery and gurgly. He has a history of pneumonia during the last year, as reported by him. He claims that he does not have a fever or shortness of breath. No history of asthma or allergies was reported by the patient.
Current Medications: Focused SOAP Note Of Coughing Patient

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Assignment
1. Purple-like syrup
2. Daily Multivitamin
Allergies: NKDA
PMHx: Denies past hospitalizations or surgical history. Reports history of pneumonia and earaches. All immunizations are current, flu vaccine not received in the past one year
Soc Hx:
• 3rd grader
• Attendance record: out for two weeks last year due to pneumonia
• Lives with the mother and father, grandmother provides care while parents work.
• English primarily spoken in home, but some Spanish is used.
Fam Hx:
• Father: hypercholesterolemia, hypertension, smoker, childhood asthma
• Mother: obesity, hypercholesterolemia, hypertension, type 2 diabetes.
• Maternal Grandfather: eczema, smoker.
• Maternal grandmother: HTN, type 2 diabetes
• Paternal grandfather: no known history
• Paternal grandmother: deceased in a car accident
ROS: Focused SOAP Note Of Coughing Patient Assignment
GENERAL: Reports constant fatigue. Denies fever, chills, or weight change
HEENT:
Eyes: Denies eye pain or vision problems.
Ears: Reports right ear pain. Denies hearing loss
Nose: Reports clear nasal discharge
Mouth/throat: Reports sore throat. Denies swallowing problems
SKIN: Denies rash or itching.
CARDIOVASCULAR: Denies chest pain, pressure, or tightness. Denies palpitations or edema.
RESPIRATORY: Reports a gurgly and watery cough. Denies shortness of breath or wheezing
GASTROINTESTINAL: Denies abdominal pain, nausea, vomiting or diarrhea.
GENITOURINARY: Denies any problems
NEUROLOGICAL: Denies headache, dizziness, or vertigo.
MUSCULOSKELETAL: Denies joint, back pain, or muscle pain.
HEMATOLOGIC: Denies bleeding or history of anemia.
LYMPHATICS: Denies enlarged nodes
PSYCHIATRIC: Denies history of anxiety or depression.
ENDOCRINOLOGIC: Denis heat or cold intolerance, or sweating
O.
Physical exam:
General: pleasant and fatigued appearing male, coughing constantly. Alert and oriented x 4,
HEENT: Head is atraumatic and normocephalic. Dullness noted in the eyes. Moist and pink conjunctiva, white sclera. Erythema noted in right tympanic membrane and auditory canal. Left tympanic membrane pearly grey, auditory canal pink. Moist and pink mucous membranes, clear nasal discharge. Nasal turbinate patent bilaterally. Posterior oropharynx with cobblestoning and erythema. Erythema in tonsils.
Neck: symmetric, no masses, swelling, discoloration. Right cervical lymph nodes palpable and tender.
Respiratory: Regular and increased respiratory rate, no SOB or distress noted. Breath sounds clear to auscultation no adventitious sounds. Expected fremitus. Spirometry, Chest wall resonant to percussion.: FEV1: 3.15 L, FVC 3.91 (FEV1/FVC: 80.5%)
Cardiovascular: S1, S2 auscultated with no murmurs, gallops, or rubs.
Diagnostic results: Vital signs: Temp 37.2C BP-120/26, O2-96% RA, HR-100. Spirometer: FVC: 1.78L, FEV1 1.549L (FEV1/FVC:87%)
A.
Differential Diagnoses: Focused SOAP Note Of Coughing Patient Assignment
• Upper respiratory infection: It affects the upper respiratory tract, including the nose and throat. An upper respiratory infection may be diagnosed based on the presence of many symptoms, including a cough, a sore throat, and a runny or stuffy nose. Upper respiratory infections are often treated with rest, fluid intake, and over-the-counter pain relievers, among other methods (Aplin-Snider et al., 2020). Danny’s symptoms, which include a cough, runny nose, and a sore throat, point to this as a possibility.
• Acute otitis media: This is a frequent illness that affects children that is characterized by inflammation of the ear drum. The inflammation may be caused by a traumatic event or an infection caused by bacteria, fungus, or virus (Paul & Moreno, 2020). Otalgia, fever, a sudden loss of appetite, and headache are the symptoms that first reveal themselves in patients with this condition.
• Strep throat: Itchy and scratchy throat symptoms are common symptoms of strep throat, a bacterial infection that causes pain in the throat. This virus is very infectious and is often transmitted by airborne droplets when an infected individual coughs, sneezes, or is in contact with another person. Sore throat, difficulty swallowing, enlarged tonsils, enlarged lymph nodes, fever, and other symptoms are common for a patient with strep throat. Focused SOAP Note Of Coughing Patient Assignment

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• References
Aplin-Snider, C., Cooper, D., Dieleman, P., & Smith, A. (2020). Development and implementation of an upper respiratory infection treatment protocol in a primary care health clinic. Journal of Primary Care & Community Health, 11, 215013272096681. https://doi.org/10.1177/2150132720966811
Ashurst, J. V., & Edgerley-Gibb, L. (2018). Streptococcal pharyngitis. https://www.ncbi.nlm.nih.gov/books/NBK525997/
Paul, C. R., & Moreno, M. A. (2020). Acute otitis media. JAMA Pediatrics, 174(3), 308. https://doi.org/10.1001/jamapediatrics.2019.5664 Focused SOAP Note Of Coughing Patient Assignment