with Cough | Full SOAP Note 2025
, Below is a complete, submission-ready i-Human Case Study tailored to Week 4 – 18-
Month-Old with Cough, written to align with Walden / NRNP grading rubrics (2025
format). This is formatted exactly like a high-scoring SOAP note with clinical depth, pediatric
focus, and evidence-based rationale.
i-Human Case Study
Week 4: 18-Month-Old Pediatric Patient With Cough
Course: NRNP (Primary Care / Pediatric Focus)
Year: 2025
Patient Information
Age: 18 months
Gender: Male
Source of History: Mother (reliable historian)
Chief Complaint (CC):
“My baby has been coughing and congested for the past few days.”
History of Present Illness (HPI)
The patient is an 18-month-old male who presents with a 3-day history of cough and nasal
congestion. The cough is described as intermittent, nonproductive, and worse at night. The
mother reports clear nasal discharge, decreased appetite, and mild irritability. There is no
history of fever >38°C (100.4°F), vomiting, diarrhea, or rash. No choking episodes or foreign
body aspiration concerns. The child continues to have adequate wet diapers and normal
stooling.
The patient attends daycare, where several children recently had “colds.” No recent travel.
No exposure to tobacco smoke.
Past Medical History (PMH)