SOAP Notes 1 Pediatrics

Sample Answer

Reason for Seeking Health Care Cough

HPI S.P is an 8-year-old AA male accompanied by his mother to the pediatric clinic with a chief complaint of cough. The mother states that the cough began five days ago. The cough worsens at nights interfering with his sleep. The boy states that the cough is mildly productive with clear sputum and is accompanied by a stuffy nose. He reports that two days ago he started having a mild fever and felt some chest tightness with breathing. He also reports having a sore throat, mild headache, and generalized fatigue. The mother had given the boy Cetrizine syrup but it was no effective in reducing the productive cough.

Allergies

• NKDA

Current perception of Health

• Fair

Past Medical History

• Major/Chronic Illnesses: No chronic illnesses
• Trauma/Injury: No history of trauma
• Hospitalizations: No history of admission.

Past Surgical History

• No history of surgery

Medications

• OTC Cetrizine syrup for cough.

Family History

• The paternal great grandfather died from Liver cancer at 89 years.
• The maternal grandmother has HTN and DM.
• Paternal grandfather has COPD and heart failure.
• The parents are alive and well.
• The elder brother has eczema.

Social history

The boy lives with his parents and elder brother. The boy is in 3rd grade. The mother denies exposure to smoke, ETOH, or recreational drugs. His hobbies are drawing and watching cartoon. The patient denies being sexually active.

• Family Composition: Father and mother

Health Maintenance

• Screening Tests: Visual and hearing screening one year ago.
• Exposures: No exposure to lead.
• Immunization HX: Last Flu shot-9 months ago. Immunization is up-to-date.

Review of Systems

General

• Reports mild fever and generalized fatigue. Denies chills or weight changes.

HEENT

• Eyes: Denies eye pain, blurred or double vision, or excessive lacrimation.
• Ears: Denies hearing loss and or discharge.
• Nose: Reports stuffy nose and nasal secretions. Denies sneezing or epistaxis.
• Throat: Reports sore throat.

Neck

• Denies neck pain or stiffness.

Lungs

• Reports productive cough, clear sputum, and some chest tightness with breathing. Denies wheezing.

Cardiovascular

• Denies dyspnea on exertion, edema, or palpitations.

GI

• Denies vomiting, abdominal pain, bloating, diarrhea, constipation, or black tarry stools.

Neuro

• Reports mild headache. Denies dizziness, fainting, muscle weakness, or tingling sensations.

Musculoskeletal

• Denies muscle pain, joint stiffness, or pain.

Activity &Exercise

• Denies activity intolerance.

Derm

• Denies skin discoloration, bleeding, rashes or lesions.

Physical Exam

BP 106/66; TPR 99.86 HR 94; RR 20; Ht. 51’9; Wt. 59 pounds; Percentile 57

General

The child is calm, alert, and oriented. H is neat and appropriately dressed. He shows no signs of distress but is mildly lethargic.

• HEENT: Head is symmetrical, normocephalic, and atraumatic. No lesions noted.
• Eyes: Non-inflamed sclera and conjunctiva; PERRLA. EOMs intact.
• Ears: Ear canals patent, ear wax present, tympanic membrane intact. Mastoid bone non-inflamed.
• Nose: Clear mucous discharge present. Nasal mucosa is pink; nasal septum well-aligned.
• Throat: Pink and moist oral mucosa. Tonsillar gland and pharynx are non-erythematous.
• Neck: Full ROM; non-palpable cervical lymph nodes and occipital nodes. Thyroid gland normal.
• Pulmonary: Smooth respirations; Unlabored breathing; No use of accessory muscles. Diffuse inspiratory stridor heard on auscultation. No wheezing.
• Cardiovascular: No jugular vein distension and edema noted. S1, S2 present with regular rate and rhythm. On auscultation, heart rubs, bruits and murmurs are absent. Capillary refill time 2 seconds. No central or peripheral cyanosis present.
• Derm: The skin is brown, clean, warm, dry, and intact. No rashes, bruises or lesions noted. Skin pinch goes back immediately.

1. Productive cough
2. Inspiratory stridor
3. Sore throat
4. Mild fever
5. Chest tightness

Plan

Differential Diagnoses

1. Influenza
2. Viral Pharyngitis
3. Community Acquired Pneumonia (CAP)

Principal Diagnoses

1. Acute Bronchitis

Plan

Diagnosis

• Acute Bronchitis

Diagnostic Testing

Chest to rule out pneumonia (Nowicki & Murray, 2020). Throat swab for the culture of respiratory secretions for influenza virus.

Pharmacological Treatment

1. Dextromethorphan/guaifenesin 5 mL orally every four hours. This is an antitussive recommended for temporary control of cough caused by minor throat and bronchial irritation (Sung et al., 2023).
2. Tylenol 325 mg orally 6 hourly. This is an analgesic indicated to relieve fever, lethargy, and malaise associated with Acute bronchitis (Sung et al., 2023).

Education

The caregiver was advised to give the child warm fluids for hydration. Te child was advised to have adequate rest until the fever abated. The patient was taught to cover his nose and mouth when coughing to prevent spread of the virus (Nowicki & Murray, 2020). He was advised to wash his hands often to control virus spread. He was advised to avoid smoke since it causes bronchial irritation and trigger the symptoms (Abbas et al., 2023). The mother was recommended on ensuring their home was smoke-free and no one smoked around the child.

Referrals

Refer to a pediatric pulmonologist if the patient develops severe complications or symptoms do not improve with treatment (Schubert Kühlein & Burggraf, 2023).

Follow-up

A follow-up visit was not necessary at this point. However, the mother was informed to seek immediate medical consult if the respiratory symptoms worsen or if the child has shortness of breath, vomiting, high fever, or persistent cough (Schubert Kühlein & Burggraf, 2023).

Anticipatory Guidance

Adhere to the annual Influenza vaccine to reduce the recurrence of upper respiratory tract infections. The patient and caregiver were educated on contact isolation measures like hand washing or using hand sanitizers to prevent spreading the causative virus. The mother was advised to maintain a clean air environment for the child and ensure the house is smoke-free (Abbas et al., 2023).

Signature (with appropriate credentials) __________________________________________

References

• Abbas, A. H., Mustafa, M. A., & Abozaid, M. (2023). Prevalence and risk factors of patients with chronic bronchitis among Iraqi adults. Journal of Medicine and Life, 16(3), 419–427. https //doi.org/10.25122/jml-2022-0284
• Nowicki, J., & Murray, M. T. (2020). Bronchitis and Pneumonia. Textbook of Natural Medicine, 1196–1201.e1. https //doi.org/10.1016/B978-0-323-43044-9.00155-2
• Schubert, N., Kühlein, T., & Burggraf, L. (2023). The conceptualization of acute bronchitis in general practice – a fuzzy problem with consequences? A qualitative study in primary care. BMC Primary Care, 24(1), 92. https //doi.org/10.1186/s12875-023-02039-z
• Sung, F. C., Wei, C. C., Muo, C. H., Tsai, S. P., Chen, C. W., Hsieh, D. P. H., Chen, P. C., & Lu, C. Y. (2023). Acute Bronchitis and Bronchiolitis Infection in Children with Asthma and Allergic Rhinitis A Retrospective Cohort Study Based on 5,027,486 Children in Taiwan. Viruses, 15(3), 810. https //doi.org/10.3390/v15030810