Episodic/Focused SOAP Note Template

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.  Episodic and Focused Soap Note Template

Current Medications:

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:

• 3^rd 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:

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%)

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A.

Differential Diagnoses:

• 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.

HPI: Danny Rivera is an 11-year-old Hispanic male who comes in today with c/o a cough that started five days ago. He reports the cough is worse at night and keeps him up. He voices general fatigue due to lack of sleep. He c/o pain to right ear and soreness to throat. He states his mother gave him a spoon full of “purple syrup that taste like grape.” for his cough this morning. He reports having a runny nose and coughing up “slimy clear stuff”. He reports history of having pneumonia in the past year. He denies fever, trouble breathing, or trouble swallowing. Reports pain 3/10 to right ear. Denies any pain to left ear. Reports his mom states he use to get earaches a lot. Report no allergies, hx of asthma, or use of an inhaler.  Episodic and Focused Soap Note Template

Current Medications:

1. Daily Multivitamin
2. Cough Syrup (Name unknown at this time)

Allergies: NKDA

PMHx: No surgical hx. No past hospitalizations. Pneumonia last year (treated at urgent care clinic). Earaches in the past

• No influenza vaccine in the past 12 months
• Hep B- 3 dose series completed at 6 months
• Hep A- 2 dose series completed at 15 months
• Pneumococcal 4 dose series completed at 15 months
• DTaP- 5 dose series completed at 6 years
• MMR- 2 dose series completed at 6 years
• Varicella 2 dose series completed at 6 years
• Polio- 4 dose series completed at 6 years.

Soc Hx:

• 3^rd 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:

• Mother: type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity.
• Father: smoker, HTN, hypercholesterolemia, asthma as child.
• Maternal grandmother: type 2 diabetes, hypertension.
• Maternal Grandfather: smoker, eczema.
• Paternal grandmother: died in a car accident (52 years old).
• Paternal grandfather: no known history

ROS:

GENERAL:  C/o pain to right ear and throat d/t constant cough. Voices feeling tired d/t cough being worse at night. AOx4. Appears fatigued. Speech clear and coherent. Coughs frequently, no distress noted at this time. Well-groomed and well nourished.

HEENT

Eyes: Appear dull. Bil conjunctivas moist/pink, no drainage noted. Bil sceleras white.

Ears: Erythema noted to right auditory canal. Erythema with no drainage noted to right tympanic membrane. No bulging, perforation, retractions or discharge noted. Left auditory canal pink. Left tympanic membrane pearly gray with no discharge, fluid, visible scars, bulging, perforations, or retractions noted. Right ear cone of 5:0, left ear cone of light 7:0.

Nose: Nasal cavities pink and patent with clear nasal drainage noted. Moist mucus membranes. No perforated/deviated septum or lesions noted.

Mouth/throat: Moist oral mucosa. Erythematous tonsils noted bilaterally. Redness and cobble-stoning noted in posterior oropharynx.

Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

Neck: Neck symmetrical with no masses and no tracheal deviations noted.

SKIN:  Denies rash or itching. No issues noted

CARDIOVASCULAR:  S1 and S2 audible. No murmurs, gallops, or friction rubs noted.

RESPIRATORY: Reports coughing up “slimy clear stuff.” Chest wall and diaphragmatic excursion symmetrical. No increase in effort of breathing noted. Speaks in full sentences without any SOB noted. Breath sounds clear in all areas. Negative bronchophony. Chest wall resonant in all areas, no dullness noted.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY:  Denies any issues at this time

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS: Right cervical lymph node enlarged tenderness noted.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

O.

Physical exam: Danny is a pleasant 8-year-old Hispanic male, who appears fatigued from constant cough. He is alert and oriented x 4, a good historian, with clear speech and no apparent cognitive deficits. Head is normocephalic and atraumatic. Frontal and maxillary sinuses palpated, no tenderness reported. Eyes are dull in appearance. Conjunctiva moist and pink bilaterally with no discharge. Sclera white bilaterally. Right auditory canal and tympanic membrane inflamed and red on inspection, without discharge or excess cerumen. Right cone of light not distorted, 5:00. Left auditory canal pink, tympanic membrane pearly gray with no discharge or excess cerumen. Left cone of light not distorted, 7:00. Mucous membranes pink/moist, with clear nasal discharge and rhinorrhea. Nasal turbinate patent bilaterally. Oral mucosa moist/pink. Erythema and cobble-stoning visualized in posterior oropharynx. Bilateral tonsils with erythema. Post-nasal drip not visualized. Neck is symmetric, without visible swelling, pulsation, discoloration, or masses. Right cervical lymph nodes palpable, with reported tenderness on palpation. Left cervical nodes not palpable. No palpable axillary or supraclavicular nodes. Respiratory rate is regular and increased, but no SOB or distress noted. Able to speak in full, complete sentences. Chest wall symmetric, without use of accessory muscles while breathing. Breath sounds in all fields are clear to auscultation with no adventitious sounds. Negative bronchophony. Chest wall resonant to percussion in all fields, no areas of dullness. Expected fremitus palpated equally bilaterally. Spirometry: 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: B/P-120/26, O2-96% RA, HR-100, TEMP 37.2C

Spirometer: FVC: 1.78L, FEV1 1.549L (FEV1/FVC:87%)

A.

Differential Diagnoses: Common cold with acute cough, right otitis media, and Strep throat. Differentials are based on abnormal findings affecting the ears, upper respiratory tract, and lymphatic regions. Episodic and Focused Soap Note Template

• Common cold with cough: is caused by many different types of viruses, but is usually harmless. According to the CDC, when viruses that cause colds first infect the nose and sinuses, the nose makes clear mucus. This helps wash the viruses from the nose and sinuses. After 2 or 3 days, mucus may change to a white, yellow, or green color. This is normal and does not mean that antibiotics are needed. Within two weeks symptoms of runny nose, sneezing, and congestion usually resolve themselves. Severe symptoms of SOB, dehydration and high fever in children are reasons to seek medical attention. Over-the-counter products and home remedies can help control symptoms (CDC, 2021).
• Acute otitis media: is a common pediatric emergency associated with inflammation of the ear drum. The etiology of the inflammation can be trauma or infection by bacteria, fungi, or viruses. The presenting complaints in otitis media are otalgia, fever, recent onset of anorexia, and headache. The inflammation causes the bulging of the tympanic membranes, erythema, and opacity. According to the American pediatrics association, the etiology of otitis medical is classified into host factors, infectious factors, allergic factors, and environmental factors. Factors related to allergies are allergic rhinitis. Environmental factors are passive smoke exposure and infant feeding methods. Infectious factors include viral and bacterial pathogens (Vanneste, P., & Page, C. 2019). The host factors are the immune system, anatomic structures, and genetic predisposition.
• Strep throat: Strep throat is a bacterial infection that causes soreness and scratchiness in the throat. Only a tiny percentage of sore throats are caused by strep throat. Strep throat may lead to problems such as kidney irritation or rheumatic fever if left untreated. This is a bacterial infection caused by Streptococcus pyogenes also known as Group A Streptococcus. This infection is highly contagious usually spread through airborne droplets when the infected person coughs, sneezes or through sharing of utensils and straws. This causes the patient to experience sore throat, painful swallowing, red and swollen tonsils with white patches or pus, swollen lymph nodes, fever, and many more. This most commonly affects children, but it also affects different ages. According to the CDC, the best way to keep from getting or spreading group A strep is to wash your hands often. This is especially important after coughing or sneezing. Antibiotics is the best solution to cure strep throat. Upon appreciate diagnostic testing and results, an effective treatment plan will be initiated.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Centers for Disease Control and Prevention. (2021, October 6). Common cold. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/antibiotic-use/colds.html

Centers for Disease Control and Prevention. (2022, June 27). Strep throat: All you need to know. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/groupastrep/diseases-public/strep-throat.html

Vanneste, P., & Page, C. (2019). Otitis media with effusion in children: Pathophysiology, diagnosis, and treatment. A review. Journal of otology, 14(2), 33-39.

https://doi.org/10.1016/j.joto.2019.01.005

Episodic and Focused Soap Note Template