Week 4: Focused Exam: Cough SOAP Note 2
SUBJECTIVE DATA:
Chief Complaint: The patient reports, “I guess I have been sick. I have been coughing a
lot.”
History of Present Illness: Danny Rivera is an 8-year-old male presenting today with a
cough starting five days ago. The patient states he has been coughing every couple of
minutes. The patient describes his cough as “watery and gurgly” with clear sputum
production. The patient states that his cough is becoming worse at night, which has been
affecting his sleep. As a result, he is tired during the daytime due to lack of sleep. He
reports having pain in his right ear in addition to a sore throat, both rated 3 out of 10. The
patient reports having frequent runny noses and claims to have ear infections often and
having pneumonia within the last year. The patient reports being given a purple cough
syrup by his mother, which caused temporary relief. The patient denies headache, fever,
chills, difficulty breathing, chest pain, dizziness, blurry vision, nosebleeds, recent weight
loss or loss of appetite.
Past Medical History: Pneumonia (within the past year), frequent colds, and ear
infections.
Past Surgical History: None
Family History:
Mother: Type 2 diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity.
Father: smoker, HTN, hypercholesterolemia, asthma as a child.
Maternal grandmother: Type 2 diabetes, HTN.
Maternal grandfather: Smoker, eczema.
Paternal grandmother: Died in a car accident (52 years old).
Paternal grandfather: no known history.
Social History: The patient lives with both his parents and grandparents. The patient is in
the third grade. The patient reports that the father smokes cigars inside the home. The
patient reports feeling safe at home. English is primarily spoken at home, but some
Spanish is used.
Medications: Daily multivitamin. The patient reports taking purple cough syrup from the
patient’s mother.
Allergies: NKDA
OBJECTIVE DATA:
Vital Signs:
Height: 4’ 2”
Weight: 90lbs
Blood Pressure: 120/76
Week 4: Focused Exam: Cough SOAP Note 3
Pulse Oximetry: 96% on RA
Respiratory Rate: 28 breaths per minute
Temperature: 37.2 C
Spirometry: FVC 1.78L, FEV1 1.549L
General Survey: The patient is seated on the exam table and appears fatigued but in no
acute distress. The patient coughs frequently. The patient's vital signs are stable.
Caregiver present during history and examination.
HEENT: The head is normocephalic and atraumatic. The patient’s sclera is white, and
the conjunctiva is moist and pink without discharge. The right auditory canal and
tympanic membrane are erythemic. The nasal cavities are pink and patent with clear
discharge. Mucus membranes are moist, and nasal discharge is clear. The patient's throat
shows evidence of erythema and cobble stoning. The right cervical lymph node is
enlarged, palpable, and tender.
RESPIRATORY: The patient displays an increased respiratory rate of 28 breaths per
minute. Lungs are clear to auscultation, the patient can speak in complete sentences, and
bronchophony is negative. The patient has fremitus as expected, bilateral, and equal.
CARDIOVASCULAR: S1, S2, present without murmurs, rubs, clicks, or gallops.
ASSESSMENT:
Diagnosis 1: Acute Viral Rhinitis: Acute viral rhinitis, often known as the common cold, is
caused by a respiratory viral infection that results in inflammation of the nasal mucosa. It is
common among young children and is characterized by sneezing, a runny nose, congestion,
cough, postnasal drip, watery eyes, ear pain, and difficulty swallowing. (Shoukat et al., 2019).
Diagnosis 2: Ear Infection: If a person gets a cold or sinus infection, they may develop fluid
build-up behind their eardrum. This can create an environment where bacteria and viruses can
thrive, leading to an ear infection. Signs of an ear infection may include ear pressure or fullness,
ear pain, and loss of balance. In this case, the patient's right ear pain and upper respiratory
symptoms could be due to an ear infection (Baydyda et al., 2020).
Diagnosis 3: Influenza: A respiratory tract infection commonly seen in children caused by a
virus is called a common cold. Symptoms include fever, headache, runny nose, fatigue, cough,
and eye and ear pain. The patient exhibited multiple of these symptoms. People who have
experienced pneumonia are more susceptible to contracting influenza. (Badyda et al., 2020)
PLAN:
Week 4: Focused Exam: Cough SOAP Note 4
Pharmacological Interventions: The patient will benefit from an antitussive treatment such as
Robitussin or Dimetapp. Acetaminophen to manage pain and discomfort.
Nonpharmacological Interventions: The patient may benefit from taking honey and saline
nasal spray for comfort.
Further Diagnostics or Testing: Strep culture should be obtained to rule out possible strep
throat.
Referrals: The patient will be seen by an allergist and pulmonologist to rule out any new
allergies and to complete a pulmonary function test to rule out asthma.
Patient Education: The patient and caregiver must be educated on the signs and symptoms of a
worsening condition. Additionally, the caregiver will benefit from being educated on the health
risks of her and her son being exposed to secondhand smoke.
Follow-up: The patient will follow up in two to four weeks to determine if additional
interventions are necessary. The caregiver will bring the patient back to the clinic if symptoms
become worse or life-threatening to report to the emergency department.
References
Week 4: Focused Exam: Cough SOAP Note 5
Badyda, A., Feleszko, W., Ratajczak, A., Czechowski, P. O., Czarnecki, A., Dubrawski, M., &
Dąbrowska, A. (2020). Upper respiratory symptoms in children (3-12 years old) exposed
on different levels of ambient particulate matter. Occupational and Environmental Health.
https://doi.org/10.1183/13993003.congress-2020.1303
Shoukat, N. (2019). Upper respiratory tract infections in children age 2 to 10 years in Quetta: A
prevalence study. Pure and Applied Biology, 8(2).
https://doi.org/10.19045/bspab.2019.80050
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