Student Name: Brougan Sheets Patient Initials: _____
Course:626L
Date: 1/15/25
Practicum Comprehensive SOAP Note
CC Cough, congestion and fever for 2 weeks, significant worsening in
S HPI
last 24 hours.
14-month-old female presents to the office today with her mother,
who provides the history, for evaluation of cough fever and
congestion for the past 2 weeks. Mother reports that her daughter
has had a dry occasionally “hacking” cough and some congestion
for the past 2 weeks, but she was not “sick” seeming other than
that. Then yesterday she was acting like she did not feel good and
was not eating her solid food like she had been. Then last night she
started with a "barking, seal cough". She was also warm to touch,
but they did not check her temperature. According to the mom, she
just feels that she has had fevers, but she has not actually measured
her temperature. Mom states that her brother had a cough 4-5 days
ago that has now resolved. Brother is in school setting and is
unimmunized. The patient is unimmunized. She has had normal
appetite. Normal wet diapers. No increased work of breathing at
rest, but mom states today she seemed short of breath after a crying
episode, and she always seems short of breath during her coughing
fits.
Current/PMH
No Current or Past Medical History
Birth History
• Birth
Length: 20.75" (52.7 cm)
Weight: 3.317 kg (7 lb 5 oz)
• Apgar
One: 8
Five: 10
• Discharge Weight: 3.147 kg (6 lb 15 oz)
• Delivery Method: Vaginal, Spontaneous
• Gestation Age: 39 3/7 wks
• Feeding: Breast Fed
Maternal age 29
Complications -home water birth
Risk Factors -none
Neonatal interventions required- none documented. Unable to
obtain as there was no medical presence at the birth
GBS -not documented. See above
Cardiac Screen: Pre-ductal 99 post-ductal 96 (5 days later when
seen for newborn visit)
Hearing Screen: passed
, Student Name: Brougan Sheets Patient Initials: _____
Course:626L
Date: 1/15/25
Total Bili not completed. Mother refused
PKU normal NDL
Blood Type unknown, mother refused testing
Hep B vaccine not given. Mother refused
Vitamin K administration: Mother refused
Antibiotic ophthalmic treatment: mother refused
Surgical Hx
No surgical history
Medications No medications
Allergies
No known allergies to medication, food or environment
Family Hx
No significant Family History
Social Hx Lives with mother, father, two sisters, one brother, grandmother
No smoking in the home
No Pets in the home
Day/Home Care Future Plans: Home with mother until 6 months
and then daycare
ROS Review of Systems
Constitutional: Positive for Fever (subjective). Negative for
activity change and appetite change.
HENT: Positive for congestion and rhinorrhea.
Respiratory: Positive for cough and stridor. Negative for wheezing.
Gastrointestinal: Negative for diarrhea and vomiting.
Genitourinary: Negative for decreased urine volume.
Skin: Negative for rash.
Psychiatric/Behavioral: Positive for sleep disturbance.
Immunization The child is not up to date on any vaccinations. They child has
s never had a vaccination and neither have her sibling. The parents
were vaccinated during their childhood.
Exam Pulse: 161
O Resp:
Temp:
SpO2:
Weight:
26
97.8 °F (36.6 °C)
99%
9.185 kg (20 lb 4 oz)
HENT:
Head: Normocephalic and atraumatic.
Course:626L
Date: 1/15/25
Practicum Comprehensive SOAP Note
CC Cough, congestion and fever for 2 weeks, significant worsening in
S HPI
last 24 hours.
14-month-old female presents to the office today with her mother,
who provides the history, for evaluation of cough fever and
congestion for the past 2 weeks. Mother reports that her daughter
has had a dry occasionally “hacking” cough and some congestion
for the past 2 weeks, but she was not “sick” seeming other than
that. Then yesterday she was acting like she did not feel good and
was not eating her solid food like she had been. Then last night she
started with a "barking, seal cough". She was also warm to touch,
but they did not check her temperature. According to the mom, she
just feels that she has had fevers, but she has not actually measured
her temperature. Mom states that her brother had a cough 4-5 days
ago that has now resolved. Brother is in school setting and is
unimmunized. The patient is unimmunized. She has had normal
appetite. Normal wet diapers. No increased work of breathing at
rest, but mom states today she seemed short of breath after a crying
episode, and she always seems short of breath during her coughing
fits.
Current/PMH
No Current or Past Medical History
Birth History
• Birth
Length: 20.75" (52.7 cm)
Weight: 3.317 kg (7 lb 5 oz)
• Apgar
One: 8
Five: 10
• Discharge Weight: 3.147 kg (6 lb 15 oz)
• Delivery Method: Vaginal, Spontaneous
• Gestation Age: 39 3/7 wks
• Feeding: Breast Fed
Maternal age 29
Complications -home water birth
Risk Factors -none
Neonatal interventions required- none documented. Unable to
obtain as there was no medical presence at the birth
GBS -not documented. See above
Cardiac Screen: Pre-ductal 99 post-ductal 96 (5 days later when
seen for newborn visit)
Hearing Screen: passed
, Student Name: Brougan Sheets Patient Initials: _____
Course:626L
Date: 1/15/25
Total Bili not completed. Mother refused
PKU normal NDL
Blood Type unknown, mother refused testing
Hep B vaccine not given. Mother refused
Vitamin K administration: Mother refused
Antibiotic ophthalmic treatment: mother refused
Surgical Hx
No surgical history
Medications No medications
Allergies
No known allergies to medication, food or environment
Family Hx
No significant Family History
Social Hx Lives with mother, father, two sisters, one brother, grandmother
No smoking in the home
No Pets in the home
Day/Home Care Future Plans: Home with mother until 6 months
and then daycare
ROS Review of Systems
Constitutional: Positive for Fever (subjective). Negative for
activity change and appetite change.
HENT: Positive for congestion and rhinorrhea.
Respiratory: Positive for cough and stridor. Negative for wheezing.
Gastrointestinal: Negative for diarrhea and vomiting.
Genitourinary: Negative for decreased urine volume.
Skin: Negative for rash.
Psychiatric/Behavioral: Positive for sleep disturbance.
Immunization The child is not up to date on any vaccinations. They child has
s never had a vaccination and neither have her sibling. The parents
were vaccinated during their childhood.
Exam Pulse: 161
O Resp:
Temp:
SpO2:
Weight:
26
97.8 °F (36.6 °C)
99%
9.185 kg (20 lb 4 oz)
HENT:
Head: Normocephalic and atraumatic.
