SOAP note: Chronic cough Discussion Paper

Patient information

Patient initial: W.G. Age: 7.       Sex: male      Race: African-American

CC: ‘Persistent Cough x7 Days.’

HPI: W.G, a 7-year-old African-American male, presented to the clinic accompanied by his mother, complaining of a persistent cough for the last seven days. He also complained of a runny nose, right ear pressure, and chest discomfort. The mother claimed that the symptoms intensified during the night, compromising the client’s sleep. She claimed to have sought Benadryl medication to ease her son’s cough, but it only offered momentary relief. Denies having nausea, vomiting, or diarrhea. SOAP note: Chronic cough Discussion Paper

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Medication: Benadryl 200mg 10ml PO nocte

Allergy: he is allergic to pollen

PMH: no past medical/surgical history reported.

Immunization: up-to-date.

Family history: no significant family history was reported

Social history: The patient is in second grade at a local school. He lives in a secure area. He has never attempted to use any illegal drugs. His parents are financially secure, and he is insured. He enjoys playing football with his peers on occasion. Consumes a well-balanced diet.

ROS:

General: denies fever, chills, and changes in weight. Reported general fatigue and wheezing

HEENT: denies visual disturbances. He reported fullness in his right ear.

CV: + chest tightness. Denies irregular heartbeat

G.I.: denies nausea, vomiting, and diarrhea.

GU: denies dysuria and polyuria.

Msk: denies muscle pain.

Respiratory: reported persistent cough, which worsens the night. Denies SOB.

Skin and breast: no skin rashes or bruising reported.

Neurological: denies cold or heat intolerances SOAP note: Chronic cough Discussion Paper

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PE:

Vts: T 37.1, HR 72, RR 20, BP 93/60, SpO2 100% Wt. 66 lb. Ht. 4’5

General: Well-hydrated and appears stated age.

Skin: no rashes or bruises noted.

HEENT: normocephalic, clear nasal discharge noted.

CV: RRR, no murmur or galops

Msk: symmetrical with ROM intact.

Resp: no cyanosis. Clear lung sound.

Neurological: balanced gait. Speech clear.

Psychiatric: oriented to place and time (Forbes et al.,2020). Short-term and long-term memory intact.

A.

Lab test and result

CBC: result pending

Lung functional test: result pending

Allergy skin test

Diagnoses

Differential diagnoses

1. Childhood asthma

A chronic cough that worsens at night or after physical activity characterizes this condition (Dharmage et al.,2019). It can also cause right ear pressure, tightness in the chest, and weariness, as was shown in the case presentation—consequently, the most likely diagnosis.

Other diagnoses

1. Viral rhinitis
2. Chronic allergies

Primary diagnoses: childhood asthma SOAP note: Chronic cough Discussion Paper

P

Medication: give Flovent HFA

Education: the child must enlighten on the triggers and how to avoid them. He must always take his drug whenever he notices a symptom. Moreover, he must avoid spaces where people smoke for safety.

Follow-up: report to the clinic after four weeks of therapy for further assessment.

References

Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of asthma in children and adults. Frontiers in pediatrics, 7, 246.

Forbes, H., & Watt, E. (2020). Jarvis’s Health Assessment and Physical Examination-E-Book: Australian and New Zealand. Elsevier Health Sciences. SOAP note: Chronic cough Discussion Paper