CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) H.K. Date: 03/31/2025 Time: 1130 AM
Ethnicity: Caucasian Age: 6 Sex: Male
SUBJECTIVE (must complete this section)
CC : Per mother: "He has had this cough for, my goodness, 2 weeks or more. It seems to be getting worse, and
it keeps him up at night. Now he has a fever."
HPI: Patient is a 6-year-old Caucasian male in office with his mother for evaluation of a wheezing cough that
has been ongoing x 2 weeks. The mother reports other symptoms of productive coughing, nasal congestion,
occasional runny nose, and a fever that started last night. The mother stated she tried OTC children’s cough
medication and Vicks vapor rub. She stated this helped his symptoms but did not suppress them for long. She
stated excessive movement makes his symptoms worse.
Medications:
KinderMed Kids’ Nighttime Cold & Cough Medicine. Take 5ml every 4 hours as needed.
Vicks Vapo Rub Children Topical Chest Rub, Cough Medicine for Kids Cough Relief. Apply to neck, chest,
and back up to two times daily.
Previous Medical History: No previous medical history
Developmental History:
Allergies: Cow’s milk, Mosquito’s
Medication Intolerances: No known Medication Intolerances
Chronic Illnesses/Major traumas: No chronic illnesses or major
traumas Immunizations: Immunizations up to date. Refused
COVID/FLU Hospitalizations/Surgeries: No previous hospitalizations
or surgeries Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: appropriate dairy intake: 3 servings of milk, cheese or yogurt a day and
Calcium intake; diet includes daily vegetables and fruits; and 3 meals/day, does not skip
meals, well balanced diet, including protein and iron-rich foods, fast food <1 time per
week, <8oz. sugar containing beverages daily, adequate daily water intake, and eats
meals as a family.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Injury Prevention: no smokers in home/smokers around child, guns in
home/homes where child spends time, or concern for violence in home; has emergency
numbers/poison control number near every telephone and fire safety/escape plan; and
smoke detectors on every floor, regularly tests alarms, CO detectors on every floor,
regularly tests alarms, always uses car seat or booster seat in the back seat of car, safe
practices around pool & water, understanding of sun protection, understands insect
repellant, hot water temperature set at or below 120F, uses helmet for
biking/scootering, and no swimming lessons.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns
with child's vision: No. Anemia Screening - based on risk assessment: Does child eat a
vegetarian diet (does not eat red meat, chicken, fish, or seafood)? No, child's diet
include iron-rich foods, such as meat, iron-fortified cereals, or beans? Yes, and family
struggle to put food on the table? No.
Dyslipidemia Screening - based on risk assessment: Dyslipidemia screen indicated: No.
Tuberculosis Screening - based on risk assessment: Was child or any household
member born in, or has traveled to, a country where tuberculosis is common (Includes
countries in Africa, Asia, Latin America, Eastern Europe)? No, has child had close
contact with a person who has tuberculosis
disease or who has had a positive tuberculosis test result? No, and Is child infected with HIV? No.
, medications
MGM: Deceased at 51 years of age. History of Chronic Heart Failure after COVID-19.
MGF: 55 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
F: 30 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 56 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 57 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, nasal congestion, headache and Cardiovascular: Denial of any chest pain
ongoing cough with thick mucous
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of worsening coughing
with wheezing
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Denial of nausea,
pain vomiting, or diarrhea
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denial of
hearing disorders urinary frequency or urgency. Menstrual
cycle not started.
Nose/Mouth/Throat: Report of nasal congestion and a runny Musculoskeletal: Denial of any joint
nose swelling, aches, or pain.
Breast: denial of any pain or tenderness Neurological: Denial of any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: denial of abnormal bleeding or easy Psychiatric: Denial of any symptoms
bruising. No history of blood disorders depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
72 lbs. 0 oz 4 ft. 6 in 16.9 98/68 100.0 132 SPO2%: 98%
General Appearance: Patient is alert and sitting down on the examination table. Patient is attentive and can
answer questions when asked. Patient is noted to be febrile. Patient also noted coughing and spit up thick
mucus.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Runny nose noted. Nasal passages narrow with erythema noted. Tonsils are appropriate size, no
exudate noted. Normal mucous membranes
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 98% on room air. Productive cough noted. Wheezing noted upon auscultation.
Wheezing travels when patient coughs and/or takes a deep breath. Patient noted to grimace and voice pain
when coughing/taking deep breaths.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, and Strep throat testing performed in office.
Special Tests:
No special testing was performed.
Student Name: Course: NSG6435
Patient Name: (Initials ONLY) H.K. Date: 03/31/2025 Time: 1130 AM
Ethnicity: Caucasian Age: 6 Sex: Male
SUBJECTIVE (must complete this section)
CC : Per mother: "He has had this cough for, my goodness, 2 weeks or more. It seems to be getting worse, and
it keeps him up at night. Now he has a fever."
HPI: Patient is a 6-year-old Caucasian male in office with his mother for evaluation of a wheezing cough that
has been ongoing x 2 weeks. The mother reports other symptoms of productive coughing, nasal congestion,
occasional runny nose, and a fever that started last night. The mother stated she tried OTC children’s cough
medication and Vicks vapor rub. She stated this helped his symptoms but did not suppress them for long. She
stated excessive movement makes his symptoms worse.
Medications:
KinderMed Kids’ Nighttime Cold & Cough Medicine. Take 5ml every 4 hours as needed.
Vicks Vapo Rub Children Topical Chest Rub, Cough Medicine for Kids Cough Relief. Apply to neck, chest,
and back up to two times daily.
Previous Medical History: No previous medical history
Developmental History:
Allergies: Cow’s milk, Mosquito’s
Medication Intolerances: No known Medication Intolerances
Chronic Illnesses/Major traumas: No chronic illnesses or major
traumas Immunizations: Immunizations up to date. Refused
COVID/FLU Hospitalizations/Surgeries: No previous hospitalizations
or surgeries Health Promotion/Health Maintenance
Nutrition/Diet: Nutrition: appropriate dairy intake: 3 servings of milk, cheese or yogurt a day and
Calcium intake; diet includes daily vegetables and fruits; and 3 meals/day, does not skip
meals, well balanced diet, including protein and iron-rich foods, fast food <1 time per
week, <8oz. sugar containing beverages daily, adequate daily water intake, and eats
meals as a family.
Exercise/Regimen: Exercises every day, plays outside, limits TV/electronic use.
Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: No passive exposure and no
smokers/drinkers/drug use in home
Safety Measures: Injury Prevention: no smokers in home/smokers around child, guns in
home/homes where child spends time, or concern for violence in home; has emergency
numbers/poison control number near every telephone and fire safety/escape plan; and
smoke detectors on every floor, regularly tests alarms, CO detectors on every floor,
regularly tests alarms, always uses car seat or booster seat in the back seat of car, safe
practices around pool & water, understanding of sun protection, understands insect
repellant, hot water temperature set at or below 120F, uses helmet for
biking/scootering, and no swimming lessons.
Screening exams: Parental concerns with child's hearing: No and speech: No. Concerns
with child's vision: No. Anemia Screening - based on risk assessment: Does child eat a
vegetarian diet (does not eat red meat, chicken, fish, or seafood)? No, child's diet
include iron-rich foods, such as meat, iron-fortified cereals, or beans? Yes, and family
struggle to put food on the table? No.
Dyslipidemia Screening - based on risk assessment: Dyslipidemia screen indicated: No.
Tuberculosis Screening - based on risk assessment: Was child or any household
member born in, or has traveled to, a country where tuberculosis is common (Includes
countries in Africa, Asia, Latin America, Eastern Europe)? No, has child had close
contact with a person who has tuberculosis
disease or who has had a positive tuberculosis test result? No, and Is child infected with HIV? No.
, medications
MGM: Deceased at 51 years of age. History of Chronic Heart Failure after COVID-19.
MGF: 55 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
F: 30 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGM: 56 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
PGF: 57 years of age. Alive and well. No acute or chronic illnesses reported. No daily medications
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, nasal congestion, headache and Cardiovascular: Denial of any chest pain
ongoing cough with thick mucous
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of worsening coughing
with wheezing
Eyes: Denial of any eye discharge. Denies blurred vision or eye Gastrointestinal: Denial of nausea,
pain vomiting, or diarrhea
Ears: Denial of ear discharge. Denial of any past or current Genitourinary/Gynecological: Denial of
hearing disorders urinary frequency or urgency. Menstrual
cycle not started.
Nose/Mouth/Throat: Report of nasal congestion and a runny Musculoskeletal: Denial of any joint
nose swelling, aches, or pain.
Breast: denial of any pain or tenderness Neurological: Denial of any loss of
consciousness. Denial of any weakness
Heme/Lymph/Endo: denial of abnormal bleeding or easy Psychiatric: Denial of any symptoms
bruising. No history of blood disorders depression or anxiety
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weight: Height: BMI: BP: Temp: Pulse: Resp: 20
72 lbs. 0 oz 4 ft. 6 in 16.9 98/68 100.0 132 SPO2%: 98%
General Appearance: Patient is alert and sitting down on the examination table. Patient is attentive and can
answer questions when asked. Patient is noted to be febrile. Patient also noted coughing and spit up thick
mucus.
Skin: No cyanosis noted. No bruising or injuries noted. Patient’s skin is warm to touch
HEENT: Head is normocephalic and atraumatic. PERRLA. Right and left tympanic membrane pearly w/ good
landmarks. Runny nose noted. Nasal passages narrow with erythema noted. Tonsils are appropriate size, no
exudate noted. Normal mucous membranes
Cardiovascular: S1 and S2 sounds heard. No abnormal murmurs. No chest deformities. No edema. Capillary
refill <2 seconds on all four extremities
Respiratory: O2 saturation 98% on room air. Productive cough noted. Wheezing noted upon auscultation.
Wheezing travels when patient coughs and/or takes a deep breath. Patient noted to grimace and voice pain
when coughing/taking deep breaths.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge. No skin discoloration.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted without tenderness.
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, and Strep throat testing performed in office.
Special Tests:
No special testing was performed.
