PEDIATRIC SOAP NOTE: COUGH & CONGESTION IN 4-MONTH-OLD
BABY2024/2025
SOAP Note Name: Antonesha Lewis
Typhon Encounter #: ________ 4278-20240301-008
NU :
Herzing University Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Cough & congestion
HPI: A.R. ia a 4 month old African American male that present in the clinic
with his mother today who reports non productive cough, nasal
congestion and pulling at left ear that all started 7 days ago. She reports
cough has improved, however the congestion has not and it is causing
difficulties for the patient when trying to sleep. The patient also
continues to pull at his left ear. Mom reports that she has not given any
OTC medications to the patient. She denies fever, vomiting, or diarrhea.
She also denies any drainage from left ear or any odor.
This study source was downloaded by 100000887200375 from nursinghero.com on 08-04-2024 19:52:04 GMT -05:00
https://www.nursinghero.com/study-files/5616343
, PMH: Birth History:
A.R. was born at 37 weeks via cesarean section due to breech presentation.
She reports receiving epidural anesthesia. Mom denies any pregnancy
complications or postnatally. A.R.’s birth weight was 6lbs 6oz.18 inches long.
She reports that A.R. was head first and then turned again, they were hoping
he would turn again but that did not happen. He suffered from hip dysplasia
due to being breached and wears a Pavlik harness 23 hours a day. He is
allowed out for roughly 1 hour a day. He is being followed by the children’s
ortho clinic. Mom reports that they are having some insurance issues at the
moment and are being forced to pay out of pocket for all visits at the ortho
clinic and she cannot continue to afford it. She stated that when she figures
out insurance that she will return for his follow up appt. Mom reports A.R.
not requiring resuscitation, he was quiet and alert. Mom reports not being
able to remember his first cry. She states it may have been when he was
hungry. A.R. did leave the hospital with his parents after 72 hours.
Neonatal: (for newborn exams) Deferred
Past Illnesses- Mom reports no known past illnesses
Past Medical History: Hip dysplasia (at birth 10/2023) A.R. was born breached
This study source was downloaded by 100000887200375 from nursinghero.com on 08-04-2024 19:52:04 GMT -05:00
https://www.nursinghero.com/study-files/5616343
BABY2024/2025
SOAP Note Name: Antonesha Lewis
Typhon Encounter #: ________ 4278-20240301-008
NU :
Herzing University Comprehensive: Focused:
S: SUBJECTIVE DATA
CC: Cough & congestion
HPI: A.R. ia a 4 month old African American male that present in the clinic
with his mother today who reports non productive cough, nasal
congestion and pulling at left ear that all started 7 days ago. She reports
cough has improved, however the congestion has not and it is causing
difficulties for the patient when trying to sleep. The patient also
continues to pull at his left ear. Mom reports that she has not given any
OTC medications to the patient. She denies fever, vomiting, or diarrhea.
She also denies any drainage from left ear or any odor.
This study source was downloaded by 100000887200375 from nursinghero.com on 08-04-2024 19:52:04 GMT -05:00
https://www.nursinghero.com/study-files/5616343
, PMH: Birth History:
A.R. was born at 37 weeks via cesarean section due to breech presentation.
She reports receiving epidural anesthesia. Mom denies any pregnancy
complications or postnatally. A.R.’s birth weight was 6lbs 6oz.18 inches long.
She reports that A.R. was head first and then turned again, they were hoping
he would turn again but that did not happen. He suffered from hip dysplasia
due to being breached and wears a Pavlik harness 23 hours a day. He is
allowed out for roughly 1 hour a day. He is being followed by the children’s
ortho clinic. Mom reports that they are having some insurance issues at the
moment and are being forced to pay out of pocket for all visits at the ortho
clinic and she cannot continue to afford it. She stated that when she figures
out insurance that she will return for his follow up appt. Mom reports A.R.
not requiring resuscitation, he was quiet and alert. Mom reports not being
able to remember his first cry. She states it may have been when he was
hungry. A.R. did leave the hospital with his parents after 72 hours.
Neonatal: (for newborn exams) Deferred
Past Illnesses- Mom reports no known past illnesses
Past Medical History: Hip dysplasia (at birth 10/2023) A.R. was born breached
This study source was downloaded by 100000887200375 from nursinghero.com on 08-04-2024 19:52:04 GMT -05:00
https://www.nursinghero.com/study-files/5616343
