Download Focused Soap Note NU 508 and more Papers Nursing in PDF only on Docsity!
Module 8 Danny Rivera Focused Exam Cough Module 8 SOAP Note Subjective Information Chief Complaint: “I have been coughing a lot, and I feel kind of tired.” History of Present Illness: Danny says he has had a cough for four or five days. "Watery and gurgly" is how he characterizes the cough. He claims that his cough keeps him up at night and gets worse. He claims that his lack of sleep has left him generally exhausted. He claims that his right ear hurts. He has a slight pain in his throat. According to him, his mother used over-the-counter medication to treat his cough problems, but it only worked momentarily. He claims to have had regular ear infections as a child and to frequently get colds and runny noses. He states that he has had pneumonia within the last 12 months. He claims to have regular bowel movements. Fever, headache, lightheadedness, difficulty swallowing, nosebleeds, phlegm or sputum, chest pain, difficulty breathing, and abdominal pain are all denied by him. He disputes that activity aggravates his cough. Review of Systems: General:
Reports feeling tired from coughing every few minutes. Reports sleep disturbances at night from coughing. Denies recent weight loss, fever, or chills. Denies changes in appetite. Skin: Denies pigment changes, bruising, or rashes HEENT: Denies headaches or history of head injury. Denies problems with eyes. Denies eye itching, redness, watery or pain. Does not wear glasses. Reports history of frequent ear infections. Denies ear surgery history. Reports right ear pain from yesterday rating pain 3/10 on scale. Denies hearing difficulties or discharge. Denies ears popping or crackling. Denies nasal stuffiness. Reports running nose with clear and watery drainage. Denies bleeding, sinus pain, change in sense of smell, or sneezing. Denies mouth pain. Last dental exam a couple months ago. Reports sore throat with frequent coughing every couple of minutes. Cough is wet with clear sputum. Denies difficulty swallowing. Denies lumps or neck pain. Respiratory: Denies difficulty breathing or shortness of breath. Denies any breathing treatment (inhaler) ever used. Cardiovascular: Denies chest pain, chest tightness, or palpitations. Denies cardiac history. Gastrointestinal: Denies dysphagia, nausea, vomiting, diarrhea, or constipation. Reports daily bowel movements. Last BM was today. Neurologic: Denies seizures, weakness, or numbness. Past Medical History: Pneumonia last year (treated at urgent care clinic) Frequent ear infections Immunizations: o No influenza vaccine in the last 12 months o Hep B – 3-dose series completed at 6 months o Hep A – 2-dose series completed at 15 months o Pneumococcal – 4-dose series completed at 15 months o DTaP – 5-dose series completed at 6 years o MMR – 2-dose series completed at 6 years o Varicella – 2-dose series completed at 6 years o Polio – 4-dose series completed at 6 years Past Surgical History: Denies surgical history
Assessment & Plan Diagnosis:
- Acute Rhinitis
- Common cold
- Strep Throat
- Asthma Diagnostic Testing:
- Allergy Testing
- Lung Function Test
- Strep Culture Pharmacological Treatment:
- Antitussive treatment at night to help relieve cough and sleep at night. Non-pharmacological Treatment:
- Get plenty of rest.
- Drink plenty of fluids. Education:
- Educate the patient and caregiver about the importance of hand hygiene, covering your cough and sneeze to prevent the spread of germs.
- Continue staying active, eating a healthy, balanced diet, and daily multivitamin. Follow-up:
- RTC in 10 days if cough is cough is not resolved or worse.
- Instruct caregivers to monitor Danny for any fever, worsening symptoms of coughing, or feeling short of breath. If it gets worse, go to ER or urgent care. Rationale Danny Rivera, a pediatric patient, presents with a 4–5 day history of wet, “watery and gurgly” cough, fatigue, sore throat, right ear pain, and clear nasal drainage-- classic signs of a viral upper respiratory infection (Thomas & Bomar, 2023). However, along with the absence of fever, difficulty breathing, or chest pain, the most likely diagnoses include acute rhinitis or the common cold. His history of frequent colds and recent pneumonia further supports this assessment.
Strep throat is considered due to throat redness, cobblestoning, and tender cervical lymphadenopathy (Ashurst & Edgerley-Gibb, 2023). Although he lacks hallmark signs like fever or tonsillar exudates, a strep test is appropriate to rule out this potentially serious bacterial infection. Asthma is included in the differential due to the elevated respiratory rate and family history (Onisor & Turner, 2023). However, the patient denies wheezing or dyspnea, and normal spirometry (FEV1/FVC 87%) reduces its likelihood as a current issue. The plan of care prioritizes symptom relief and cautious evaluation (Thomas & Bomar, 2023). A nighttime antitussive is recommended to improve sleep quality, and non-pharmacologic strategies—hydration, rest, and hygiene education—support recovery and help prevent spread. Diagnostic testing (strep culture, allergy testing, lung function) is aimed at confirming or excluding the less likely but clinically relevant differentials. A follow-up in 10 days ensures ongoing evaluation and early identification of complications like bacterial superinfection or worsening respiratory function. This approach balances immediate symptom management with appropriate diagnostic vigilance and patient education, in line with evidence-based pediatric care. References
