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Danny Rivera: Episodic Soap Note and Reflection
Marlena Demczyk
University of Phoenix
NRP/571
Dr. Audrey M. Stevenson
October 4, 2024
, 2
Subjective
First Name: Danny
Last Name: Rivera
Age: 8
DOB: 06/30/2016
Gender: Male
Ethnicity: Hispanic
Chief Complaint: The patient presents with a 5-day history of sore throat, accompanied by a
wet, productive cough, with rhinorrhea.
History of Present Illness: Danny Rivera is an 8-year-old male patient brought into the office
by his grandmother with complaints of a wet cough and sore throat that began five days ago. He
reports that his cough disrupts his sleep at night, and he also experiences right ear pain rated 3
out of 10, which further interferes with his ability to sleep. He denies sinus pain, fever, and
chills. He reports a runny nose with clear drainage, and difficulty being active related to his
cough. His mother gave him purple cough medicine that only helped him briefly and he takes
vitamins daily. The patient reported his last illness was a stomach illness to which he made a
quick recovery.
Allergies (drugs and reactions): NKDA
Current Medications (drugs, doses, frequency): Daily vitamin and a purple cough medicine.
PMH: He reported having pneumonia last year, and a history of ear infections, and colds
accompanied by rhinitis. The patient has no surgical history or hospitalizations.
, 3
Family History:
Mother- Alive, Type 2 Diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity.
Father- Alive, Smoker, HTN, hypercholesterolemia, asthma as a child.
Maternal Grandmother- Alive, Type 2 diabetes, HTN
Maternal Grandfather- Alive, smoker, eczema.
Paternal Grandmother- Deceased, Passed away in a car accident at 52 years old.
Paternal Grandfather- No known history.
Social History: Danny is a third-grade student who lives with his mother, father, and maternal
grandparents, and feels safe at home with his family. His grandmother provides care for him
while his parents work. Danny stays active by playing in the playground near his home with
friends and regularly attends church with his family on Sundays.
Health Maintenance: Daily vitamins, no hospitalizations.
Pediatric History: Pneumonia last year, issues with runny nose and colds throughout childhood.
Nutrition Status: Patient appears well-developed.
Immunizations:
No influenza vaccine in the last 12 months.
Hep B, 3-dose series completed at 6 months.
Hep A, 2-dose series completed at 15 months.
Pneumococcal, 4-dose series completed at 15 months.
DTaP, 5-dose series completed at 6 years.
MMR, 2-dose series completed at 6 years.
Varicella, 2 dose series completed at 6 years.
Polio, 4 dose series completed at 6 years.
Danny Rivera: Episodic Soap Note and Reflection
Marlena Demczyk
University of Phoenix
NRP/571
Dr. Audrey M. Stevenson
October 4, 2024
, 2
Subjective
First Name: Danny
Last Name: Rivera
Age: 8
DOB: 06/30/2016
Gender: Male
Ethnicity: Hispanic
Chief Complaint: The patient presents with a 5-day history of sore throat, accompanied by a
wet, productive cough, with rhinorrhea.
History of Present Illness: Danny Rivera is an 8-year-old male patient brought into the office
by his grandmother with complaints of a wet cough and sore throat that began five days ago. He
reports that his cough disrupts his sleep at night, and he also experiences right ear pain rated 3
out of 10, which further interferes with his ability to sleep. He denies sinus pain, fever, and
chills. He reports a runny nose with clear drainage, and difficulty being active related to his
cough. His mother gave him purple cough medicine that only helped him briefly and he takes
vitamins daily. The patient reported his last illness was a stomach illness to which he made a
quick recovery.
Allergies (drugs and reactions): NKDA
Current Medications (drugs, doses, frequency): Daily vitamin and a purple cough medicine.
PMH: He reported having pneumonia last year, and a history of ear infections, and colds
accompanied by rhinitis. The patient has no surgical history or hospitalizations.
, 3
Family History:
Mother- Alive, Type 2 Diabetes, HTN, hypercholesterolemia, spinal stenosis, obesity.
Father- Alive, Smoker, HTN, hypercholesterolemia, asthma as a child.
Maternal Grandmother- Alive, Type 2 diabetes, HTN
Maternal Grandfather- Alive, smoker, eczema.
Paternal Grandmother- Deceased, Passed away in a car accident at 52 years old.
Paternal Grandfather- No known history.
Social History: Danny is a third-grade student who lives with his mother, father, and maternal
grandparents, and feels safe at home with his family. His grandmother provides care for him
while his parents work. Danny stays active by playing in the playground near his home with
friends and regularly attends church with his family on Sundays.
Health Maintenance: Daily vitamins, no hospitalizations.
Pediatric History: Pneumonia last year, issues with runny nose and colds throughout childhood.
Nutrition Status: Patient appears well-developed.
Immunizations:
No influenza vaccine in the last 12 months.
Hep B, 3-dose series completed at 6 months.
Hep A, 2-dose series completed at 15 months.
Pneumococcal, 4-dose series completed at 15 months.
DTaP, 5-dose series completed at 6 years.
MMR, 2-dose series completed at 6 years.
Varicella, 2 dose series completed at 6 years.
Polio, 4 dose series completed at 6 years.
