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[ANSWERED] Episodic SOAP Note Danny Rivera

Episodic SOAP Note Danny Rivera cough

Document: Provider Notes

Student Documentation

Model Documentation

Subjective

Danny Rivera a 8 year old male presents today with chief complains of a cough onset 5 days ago, right ear pain 3/10, feeling tired and sick. paints reports cough gurgly and watery, clear sputum and runny nose. patient denies smoking, but admits being exposed to second hand smoke. patient reported that his mother gave him OTC cough medication with did help with the cough.

N/A

Objective

v/s BP: 120/76 RR: 28 HR: 100 TEMP: 37.2 O2 SAT: 96% FVC 1.78, FEV1 1.549L (FEV1/FVC 87%) patients appear fatigued dry mucus membrane and throat erythremia noted nasal cavity red right ear canal red productive cough clear muscus noted lungs clear to auscultation no acute distress noted

N/A

Assessment

productive cough throat erythremia allergies fatigue

N/A

Plan

increase fluid intake throat culture patient and family education on smoking prescribe cough suppressant medication encourage rest (2-3 days sick level)

N/A

Comments

Your avatar         Hello. my name is ann i will your nurse practitioner today.            Greet 03/29/20 7:17 PM MDT

Danny Rivera      Hi.

Your avatar         what is your name           Question 03/29/20 7:17 PM MDT

Danny Rivera      My name is Daniel Rivera, but I just go by Danny.

Your avatar         danny who bought you here today (Clarified to Who is here with you today?.)     Question 03/29/20 7:19 PM MDT

Danny Rivera      Abuela brought me here instead of taking me to school today. (Clarified to who is here with me.)

Your avatar         why did your abuela bring in today           Question 03/29/20 7:20 PM MDT

Danny Rivera      My Abuela brought me here because I\’ve been feeling sick. I have been coughing a lot. . . and I feel kinda tired.

Your avatar         i am sorry to hear that you are not feeling well   Empathize 03/29/20 7:22 PM MDT

Danny Rivera      Thank you.

Your avatar         when did you cough start (Clarified to When did you start coughing?.)     Question 03/29/20 7:23 PM MDT

Danny Rivera      I think the cough started four. . . No, it started five days ago. (Clarified to when I started coughing.)

Your avatar         how often is your cough                Question 03/29/20 7:24 PM MDT

Danny Rivera      I just keep feeling like I have to cough every couple minutes or so. I think it gets worse at night.

Your avatar         what does it feel like when you cough     Question 03/29/20 7:25 PM MDT

Danny Rivera      I know it\’s bad. I try to leave the room if Papi forgets to go outside.

Your avatar         does it feel like a dry cough or wet cough              Question 03/29/20 7:25 PM MDT

Danny Rivera      My cough seems kind of gurgly and watery.

Your avatar         what makes the cough worst      Question 03/29/20 7:27 PM MDT

Danny Rivera      My cough mostly stays the same no matter what I do. It seems to get worse at night though.

Your avatar         what make the cough better       Question 03/29/20 7:27 PM MDT

Danny Rivera      I had some cough medicine this morning. [AUDIO COMING SOON]

Your avatar         do you know the name of the medicine (Clarified to Do you know what the cough medication’s name is?.)        Question 03/29/20 7:28 PM MDT

Danny Rivera      I don\’t know what the name of the cough medicine is. It was purple. [AUDIO COMING SOON] (Clarified to if I know what the cough medicine is called.)

Your avatar         who gave you the medicine         Question 03/29/20 7:29 PM MDT

Danny Rivera      My mom.

Your avatar         are you taking any other medication        Question 03/29/20 7:30 PM MDT

Danny Rivera      I\’m not taking any medicines every day. My mom gave me some cough medicine this morning though.

Your avatar         do you take vitamins      Question 03/29/20 7:31 PM MDT

Danny Rivera      Oh yeah, I take vitamins every day! The gummy dinosaur kind. I don\’t think I\’m supposed to, but sometimes I sneak extra ones to be super healthy!

Your avatar         it important not take too much take the recommended dose       Educate 03/29/20 7:33 PM MDT

Danny Rivera      Oh, OK.

Your avatar         do you wash you hands often     Question 03/29/20 7:33 PM MDT

Danny Rivera      I wash my hands before I eat or after I go to the bathroom.

Your avatar         thats good the washing of your hands helps to prevent germs from spreading      Educate 03/29/20 7:35 PM MDT

Danny Rivera      Oh, OK.

Your avatar         do you sneeze a lot          Question 03/29/20 7:36 PM MDT

Danny Rivera      I don\’t usually have to sneeze. My nose gets runny a lot of times though, like I have a cold.

Your avatar         does it hurt when you swallow   Question 03/29/20 7:37 PM MDT

Danny Rivera      No, I can swallow OK. It hurts a little right now because my throat is kinda sore.

Your avatar         what color is your nasal discharge             Question 03/29/20 7:39 PM MDT

Danny Rivera      You mean like when I blow my nose? It\’s clear.

Your avatar         does you ear hurt             Question 03/29/20 7:40 PM MDT

Danny Rivera      My right ear is starting to hurt a little bit . . . my left one is OK though.

Your avatar         have you see ear discharge          Question 03/29/20 7:41 PM MDT

Danny Rivera      No, nothing comes out of my ears, but my right ear kind of hurts.

Your avatar         have you ever had an ear infection           Question 03/29/20 7:42 PM MDT

Danny Rivera      The last time I had one was when I was little. Mom said I used to get them a lot. Maybe I was 2-years-old? Oh, my right ear kind of hurts now . . .

Your avatar         do you have any other health history      Question 03/29/20 7:43 PM MDT

Danny Rivera      No, just this cough right now.

Your avatar         does any one at home smokes   Question 03/29/20 7:43 PM MDT

Danny Rivera      Well . . . sometimes Papi smokes cigars in the house and my mom has to tell him to go outside. I breathe it a little bit then, but it\’s not all the time or anything. I don\’t like how it smells.

Your avatar         do you smoke    Question 03/29/20 7:44 PM MDT

Danny Rivera      No way! I know smoking is really bad–even for grown-ups. Papi smokes cigars sometimes. I don\’t like how they smell.

Your avatar         do you have any eye problem     Question 03/29/20 7:44 PM MDT

Danny Rivera      I don\’t have any problems with my eyes. I see really good and they don\’t hurt or anything. [AUDIO COMING SOON]

Your avatar         do have headaches         Question 03/29/20 7:45 PM MDT

Danny Rivera      No, my head doesn\’t hurt.

Your avatar         are you light-head or dizzy (Clarified to Do you get dizzy?.)            Question 03/29/20 7:46 PM MDT

Danny Rivera      I only get dizzy if I\’m spinning around a lot at recess. (Clarified to if I get dizzy.)

Your avatar         do you get light headed Question 03/29/20 7:46 PM MDT

Danny Rivera      No, I\’ve never felt dizzy or anything like that.

Your avatar         danny thanks for telling me about your papi smoking, i realize that you are worried   Empathize 03/29/20 7:49 PM MDT

Danny Rivera      Thank you.

Your avatar         Checked vitals  Exam Action 03/29/20 7:50 PM MDT

Your avatar         danny do you sweat a lot      Question 03/29/20 7:51 PM MDT

Danny Rivera      Only if I play outside for a long time.

Your avatar         do you feel hot  Question 03/29/20 7:51 PM MDT

Danny Rivera      My mom said I didn\’t have a fever this morning before Abuela took me here.

Your avatar         Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%) Exam Action 03/29/20 7:53 PM MDT

Your avatar         Inspected right orbital area and sclera   Exam Action 03/29/20 7:55 PM MDT

Your avatar         Inspected lower conjunctiva      Exam Action 03/29/20 7:55 PM MDT

Your avatar         Inspected upper conjunctiva      Exam Action 03/29/20 7:55 PM MDT

Your avatar         Inspected lower conjunctiva      Exam Action 03/29/20 7:56 PM MDT

Your avatar         Inspected upper conjunctiva      Exam Action 03/29/20 7:56 PM MDT

Your avatar         Performed otoscopic examination of left naris    Exam Action 03/29/20 7:56 PM MDT

Your avatar         Performed otoscopic examination of right naris Exam Action 03/29/20 7:56 PM MDT

Your avatar         Performed otoscopic examination of left naris    Exam Action 03/29/20 7:57 PM MDT

Your avatar         Performed otoscopic examination of left ear       Exam Action 03/29/20 7:58 PM MDT

Your avatar         Performed otoscopic examination of right ear    Exam Action 03/29/20 8:00 PM MDT

Your avatar         Inspected mouth      Exam Action 03/29/20 8:03 PM MDT

Your avatar         danny i am know going to take a look at you mouth and throat (No matching questions

lobe Exam Action

03/29/20 8:12 PM MDT 03/29/20 8:15 PM MDT 03/29/20 8:19 PM MDT

Danny Rivera      My nose doesn\’t hurt, really. . . it\’s just runny. It seems like it\’s always a little runny, actually. It\’s worse than usual now, though.

Your avatar    danny for physical assessment do you want abuela in the room with you (No matching questions found.) Question 03/29/20 8:21 PM MDT

Your avatar         danny for physical assessment do you want abuela in the room with you (No matching questions found.) Question 03/29/20 8:22 PM MDT

Your avatar         danny have you had the chills recently   Question 03/29/20 8:24 PM MDT

Danny Rivera      No, I haven\’t felt that.

Your avatar         Auscultated breath sounds in anterior right upper lobe  Exam Action 03/29/20 8:30 PM MDT

Your avatar         Auscultated breath sounds in anterior left upper lobe     Exam Action 03/29/20 8:31 PM MDT

Your avatar         Auscultated breath sounds in posterior left upper lobe  Exam Action 03/29/20 8:31 PM MDT

Your avatar         do yo get tired when playing (Clarified to Do you tire easily?.)      Question 03/29/20 8:35 PM MDT

Danny Rivera  I feel tired right now because I haven\’t been sleeping well lately, but usually I feel fine. It\’s just this cough. (Clarified to if I tire easily.)

Your avatar   on a scale of 1 to 10 whats your pain level (Clarified to Can you rate your current pain level on a scale of 0 to 10?.)  Question 03/29/20 8:36 PM MDT

Danny Rivera      Well, I have a little pain . . . in my right ear. Maybe almost a 3. Yeah. It\’s not too bad. (Clarified to how I would rate my pain on a scale.)

Your avatar         have you every had your hearing tested Question 03/29/20 8:37 PM MDT

Danny Rivera      A lady came to my school to give all the kids a hearing test. It was kind of cool! I was hoping I would have super hearing, but I think I was just normal . . .

Your avatar         have you every had you vision tested      Question 03/29/20 8:38 PM MDT

Danny Rivera      I never needed to do that. My friend Tony wears glasses though.

Your avatar         Checked vitals  Exam Action 03/29/20 8:44 PM MDT

Your avatar         Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%) Exam Action 03/29/20 8:48 PM MDT

Your avatar         Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%) Exam Action 03/29/20 8:48 PM MDT

Your avatar         Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%) Exam Action 03/29/20 8:48 PM MDT

Your avatar         Tested lung capacity with spirometer: FEV1: 1.78L, FVC 1.549L (FEV1/FVC: 87%) Exam Action 03/29/20 8:48 PM MDT

Your avatar         danny do you have difficulty breathing   Question 03/29/20 8:52 PM MDT

Danny Rivera      I can breathe OK, yeah . . . my nose is a little bit runny though.

Your avatar         do you have any allergies  Question 03/29/20 9:00 PM MDT

Danny Rivera      I don\’t really have any allergies. Tony has some though. He\’s allergic to bees.

Your avatar         Palpated frontal sinuses: No tenderness reported  Exam Action 03/29/20 9:10 PM MDT

Your avatar         Palpated frontal sinuses: No tenderness reported  Exam Action 03/29/20 9:10 PM MDT

Your avatar         Palpated maxillary sinuses: No tenderness reported   Exam Action 03/29/20 9:11 PM MDT

Your avatar         Palpated cervical lymph nodes: Enlarged and reported tenderness on the right side

Chief Complaint

Finding: Established chief complaint

Finding: Reports cough(Found)Pro Tip: A patient\’s chief complaint establishes any illnesses or concerns they are presenting. Asking about the chief complaint will allow the patient to voice any concerns or symptoms the patient may have.Example Question:Do you have a cough?

History of Present Illness

Finding: Asked about onset of cough

Finding: Reports cough started 5 days ago(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing.Example Question:How long have you had a cough?

Finding: Asked about frequency and duration of cough

Finding: Reports coughing every few minutes(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How frequently have you been coughing?

Finding: Asked about character of cough

Finding: Reports cough is wet(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough a wet cough?

Finding: Reports clear sputum(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you produce any phlegm or sputum with your cough?

Finding: Asked about aggravating factors for cough

Finding: Reports cough is worse at night(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your cough worse at night?

Finding: Reports exposure to secondhand smoke(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you around anyone who smokes at home?

Finding: Denies knowing what makes the cough worse(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What makes your cough worse?

Finding: Asked about relieving factors for cough

Finding: Denies resting relieves cough(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does resting help your cough?

Finding: Denies drinking water relieves cough(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does drinking water help your cough?

Finding: Asked about nasal symptoms

Finding: Reports current runny nose(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have a runny nose?

Finding: Denies sneezing(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Have you been sneezing?

Finding: Reports frequent runny nose(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you get runny noses often?

Finding: Followed up on nasal discharge

Finding: Reports nasal discharge is clear(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: What color is your snot?

Finding: Reports nasal discharge is thin(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your snot thin?

Finding: Asked about ear symptoms

Finding: Reports pain in right ear(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear pain?

Finding: Followed up on ear pain

Finding: Reports ear pain started yesterday(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: How long have you had ear pain?

Finding: Reports ear pain is a 3 out of 10(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Can you rate your ear pain on a scale?

Finding: Denies ear discharge(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have any ear discharge?

Finding: Asked about throat symptoms

Finding: Reports sore throat(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is your throat sore?

Finding: Reports \”a little\” pain with swallowing(Found)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Does it hurt when you swallow?

Finding: Asked about allergies

Finding: Denies seasonal allergies(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have seasonal allergies?

Finding: Denies food allergies(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Do you have food allergies?

Finding: Denies medication allergies(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to any medicine?

Finding: Denies allergies to animals(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to animals?

Finding: Denies latex allergy(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Are you allergic to latex?

Finding: Asked about contact with illnesses

Finding: Denies being around anyone ill at home(Available)Pro Tip: Asking a patient about the length of their current health issues solicits information relevant to the history of their present illness. Details of their current complaint will help you follow-up on any present conditions or symptoms, such as the location of their pain or the amount of pain they may be experiencing. Example Question: Is anyone sick at home?

Home Medications

Finding: Asked about home medications

Finding: Confirmed home medications(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: What medications do you take?

Finding: Reports taking a daily vitamin(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: Do you take vitamins?

Finding: Reports taking cough medicine(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: Are you taking medication for your cough?

Finding: Followed up on cough medicine

Finding: Reports cough medicine was purple(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: What color was the cough medicine?

Finding: Reports taking one spoonful of cough medicine(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: How much cough medicine did you take?

Finding: Reports mother gave him the medicine(Found)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: Who gave you the cough medicine?

Finding: Reports cough medicine provided temporary relief(Available)Pro Tip: A patient\’s home medications can provide insight into the patient\’s current treatment and its efficacy. Inquiring into medication history, dosage, and frequency will help you understand the patient\’s background and how it may affect their current situation. Example Question: Did the cough medicine make you feel better?

Past Medical History

Finding: Asked about relevant medical history

Finding: Denies asthma diagnosis(Available)Pro Tip: Inquiring into the patient\’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient\’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have asthma?

Finding: Reports immunizations as current(Available)Pro Tip: Inquiring into the patient\’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient\’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have current immunizations?

Finding: Reports past pneumonia and frequent coughs(Available)Pro Tip: Inquiring into the patient\’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient\’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Do you have a history of respiratory problems?

Finding: Denies past hospitalizations(Available)Pro Tip: Inquiring into the patient\’s relevant history can reveal past diagnoses and previous conditions or concerns. Information about the patient\’s existing health conditions, a timeline of diagnosis, symptoms, and allergies can indicate where you should follow-up for further care and treatment. Example Question: Have you ever been to the hospital?

Social Determinants of Health

Finding: Asked about exposure to secondhand smoke

Finding: Reports father smokes cigars(Found)Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:Who smokes at home?

Finding: Reports father sometimes forgets to take cigars outside(Found)Pro Tip: Asking a patient about Social Determinants of Health (SDOH) can unearth underlying social, political, or economic barriers to their health and wellbeing. Recognizing a patient’s SDOH can lead you to provide more informed and empathetic care for your patients, because you will have a greater understanding of the challenges they face.Example Question:Where does your father smoke?

Social History

Finding: Asked about living conditions

Finding: Reports living in a house with parents and grandparents(Available)Pro Tip: A patient\’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient\’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Where do you live?

Finding: Reports feeling safe at home(Available)Pro Tip: A patient\’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient\’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Do you feel safe at home?

Finding: Reports park with playground near home(Available)Pro Tip: A patient\’s social history encompasses their family and support system, living situation, and daily behaviors such as diet, exercise, sexual activity, and substance use. These factors can influence their current health and wellness. Asking about a patient\’s social history can also unveil the influence of their present illnesses in their social lives. Example Question: Is there anywhere near your home where you can play outside?

Review of Systems

Finding: Asked about constitutional health

Finding: Denies fever(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have a fever?

Finding: Denies chills(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chills?

Finding: Reports feeling \”kind of tired\”(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have fatigue?

Finding: Denies night sweats(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have night sweats?

Finding: Denies weight loss(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Has your weight changed?

Finding: Denies appetite loss(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you lost your appetite?

Finding: Asked about review of systems for HEENT

Finding: Denies ear popping or crackling(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you hear any popping sounds?

Finding: Reports history of frequent ear infections(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had ear infections?

Finding: Denies ear surgery or ear tubes(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Have you ever had surgery on your ears?

Finding: Denies headaches(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you get headaches?

Finding: Denies nosebleeds(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have nosebleeds?

Finding: Denies vision problems(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any problems with your vision?

Finding: Denies dizziness(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any dizziness?

Finding: Denies watery eyes(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have watery eyes?

Finding: Denies eye redness(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have eye redness?

Finding: Denies eye pain(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any eye pain?

Finding: Denies sinus pain(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any sinus pain?

Finding: Denies hearing problems(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any hearing problems?

Finding: Asked about review of systems for respiratory

Finding: Denies difficulty breathing(Found)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have difficulty breathing?

Finding: Denies chest tightness(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have chest tightness?

Finding: Denies chest pain(Available)Pro Tip: Understanding a patient\’s health involves a comprehensive overview of their physiological systems. This is necessary to understand what symptoms may indicate larger issues, and what treatments the patient may require. Example Question: Do you have any chest pain?

Finding: Denies history of inhaler use or breathing

Expert Answer and Explanation

SOAP Note

Patient Information:

S.

CC “coughs a lot and feels tired.”

HPI: Danny Rivera is an 8-year-old male complaining of cough that has lasted five days. The patient also feels sick, 3/10 pain in the right ear, and tired. He records that the cough is watery and gurgly, running nose, and clear sputum. Patient says that he has never smoked but has been exposed to smoke on several occasions.

Current Medications: OTC cough drug and vitamins.

Allergies: No allergies.

PMHx: Rivera mentions that he was immunized currently.

Fam Hx: His father smokes.

ROS:

GENERAL: He has watery and gurgly cough that has lasted five days and feels tired and sick.

HEENT: No headache but feels 3/10 pain in the right ear.

Throat: Sore throat.

SKIN:  Healthy.

CARDIOVASCULAR:  Healthy.

RESPIRATORY:  Healthy.

GASTROINTESTINAL:  Healthy gastrointestinal.

GENITOURINARY:  Healthy genitals.

O.

Physical exam: The patients’ vitals are BT-37.2 degrees centigrade, BP-120/76, O2 SAT: 96%, RR: 28, FEV1 1.549L, HR: 100, and FVC 1.78. The patient has no acute distress, his lungs are clear to auscultation, and appears fatigued.

Diagnostic results: According to Ball et al. (2019), throat swab can be used to test cough related conditions.

A.

Differential Diagnoses 

Common cold- The most plausible disease affecting the patient.

Sore Throat

Tonsillitis

Strep throat

Influenza

Reason for Selecting Common Cold

Common cold is a viral infection that affects people occasionally. According to Smilek (2017), the disease normally infects the throat and the nose. Merchant (2019) also mention that the disease can affect the patient for more than a week. This disease has been selected because the patient has running nose, sore throat, and tiredness which as are among the symptoms of the condition.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Merchant, A. H., Merchant, A., Bailey, J., & Merchant, J. L. (2019). An unusual case of sore throat. Australian journal of general practice, 48(1/2), 37. https://search.informit.com.au/documentSummary;dn=163156001153386;res=IELHEA

Smilek, P. (2017). Sore throat treatment. Casopis lekaru ceskych, 156(4), 203-204. https://europepmc.org/article/med/28862011

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