course material

1. DANIEL, RIVERA SOAP NOTE ON COUGH ASSESSMENT.
DANIEL, RIVERA SOAP NOTE ON COUGH
ASSESSMENT. Source and Reliability: Self and reliableSubjective: Chief Complaint: “I’ve bee
n feeling sick and have been coughing a lot.”History of Present Illness (HPI):D.R. is an 8-
year-
old Puerto Rican boy who presents with his grandmother with a complaint of sudden onset
frequent, productive cough, sore throat, rhinnorrhea and right-
sided ear pain (ear pain x 1 day) for the past 4-
5 days. He reports the ear pain 3/10and the sore throat pain 2/10. Patient states that the co
ugh is frequent and productive with clear expectorant sputum. He reports the cough is wors
e at night and that he is feeling fatigued. The patient states “I get colds a lot” and is accompa
nied with rhinnorrhea. Denies coughing with these episodes. Patient states that his mother
gave him cough medicine this morning with some relief. H/o pneumonia age 7. He denies fe
ver, chills, headache, gland swelling, shortness of breath, body aches, sinus pain, eye sympto
ms (itching, discharge, or pain) or changes in vision, changes in hearing, chest pain or rash.
Pt has a h/o recurrent ear infections in early childhood. DANIEL, RIVERA SOAP NOTE ON
COUGH ASSESSMENT.ORDER
NOW. Last ear infection age 2. Denies being around anyone with illness or recent trav
el. The patient reports that he had frequent ear infections when he was younger and was tre
ated for pneumonia lastyear at an urgent care, but was not hospitalized. Patient states that h
is father smokes at home, and although he is asked to smoke outside, patient is exposed to s
econdhand smoke at times. Patient reports that father had asthma as a child. Patient denies
allergies to medications, food, environmental, or animal allergens.Past Medical History (PM
H):Frequent ear infections when he was younger –
last infection age 2Pnuemonia last year, age 7 No hospitalizations T: 37.2 degrees Celsius
RR: 28 HR: 100 BP: 120/76 pO2: 96% on room airHeight/Weight/BMI: 127 cm 40.8 kg BMI:
25.3Physical ExamConstitutional/General survey: fatigued appearing young boy, appears
stable. Dressedappropriately, pleasant affect, good eye contact throughout visit.Skin: intact,
no notable wounds, lesions or rashes.Head: Atraumatic and normocephalic.DANIEL, RIVERA
SOAP NOTE ON COUGH ASSESSMENT.Eyes: glazed over in appearance. Sclera white,
conjunctiva moist and pink. Noconjunctival dischargeEars: Right auditory canal and
tympanic membrane is erythemic and inflamed. Leftauditory canal appears pink and
tympanic membrane pearly gray. No visible abnormalfindings such as fluid, bulging,
perforations, retractions in either ear.Nose: mucus membrane is moist with clear nasal

2. discharge.Thorat: redness and cobblestoning noted in back of throat upon inspectionLymph
nodes: Right cervical lymph node enlarged with reported tenderness to
palpation.Respiratory: Resp rate increased but in no acute distress. Able to speak in
completesentences. Breath sounds clear bilaterally, no adventitious breath sounds noted,
nobroncophony noted. Chest wall is resonant to percussion. Expected fremitus
notedequally bilaterally. Productive cough with clear sputum.Spirometry: FEV1: 3.15 L, FVC
3.9 L (FEV1/FVC: 80.5%)Cardiovascular: s1 and s2 audible, no murmurs, gallops or
rubs.Neurologic: Awake alert and oriented x3, PERRLA, +3 and brisk bilaterally.OBJECTIVE
REFLECTION:Reflect on your performance and interactions with the virtual patient. Identify
whatinformation is missing from the physical exam or state what additional exam
elementsyou would have included.DANIEL, RIVERA SOAP NOTE ON COUGH
ASSESSMENT.Some missing information prior to assessment I would have liked to review
were hisprevious chest xrays from when he was diagnosed with pneumonia 1 year ago as
well asdocumentation from urgent care clinic which diagnosed him with
pneumonia.Assessment information:8 year old hispanic-american male presents to clinic
with fatigue, cough, sore throat andright ear pain x 5 days likely related to upper
respiratory infection due to onset andpresentation symptoms, and lack of fever. Acute
Bronchitis unlikely due to clear sputumand no audible adventitious breath sounds during
auscultation. Strep throat unlikely dueto no fevers, onset of symptoms, no exudate in back
of throat. Allergies unlikely due tocough being worse at night time as well as no aggravating
or alleviating factors. Asthmaunlikely due to no audible wheezing, denies dyspnea, constant
cough, and FEV1 Ratiogreater than 80%. Pneumonia unlikely due to lack of fever, lack of
adventitious breathsounds, stable vital signs, and presentation of symptoms.Plan:Diagnosis:
Upper Respiratory InfectionDiagnostics: CBC to assess WBC, C- xray to rule out Pneumonia
due to history, Strepculture to rule out strep throat.Pharmacology: Robitussin 10ml PO
every six hours as needed for cough.Education/Counseling: Provide education to family on
use of medications.Health Promotion/Anticipatory Guidance: Encourage patient to increase
his fluidhydration, encourage rest. Provide patient and family education on signs of
worseningsymptoms. Should patient develop increased shortness of breath, fever, chills,
wheezing,patient to go to nearest emergency room for evaluation.Referrals: referral to
allergist to rule out allergiesFollow-up: Call to schedule apt if no improvement of symptoms
in 48-72 hours.Self-Assessment:In reflection, think about your experience with this case.
Based on evidence-basedpractices, would you have done anything differently in this case?A
thorough and focused health history and physical examination was preformed on
thepatient’s chief complaint to rule out possible causes of symptoms, including
upperrespiratory infection, pneumonia, strep throat, acute bronchitis, asthma, and allergies.
Iperformed a thorough HEENT and respiratory exam as well as cardiac assessment.
Witheach question of my assessment and step of my exam I felt more confident in ruling
outpossible diagnoses. The plan developed above reflects his personal chief complaint
aswell as both subjective and objective findings of my examination and assessment. As
thehealth care provider, I would not do anything different based on evidence -
basedpractice.DANIEL, RIVERA SOAP NOTE ON COUGH ASSESSMENT.