Assignment: SOAP Note Pediatric Issue

Assignment: SOAP Note Pediatric Issue

Name: Chris West Pt. Encounter Number: 2098/19
Date: 3-08-2019 Age: 2 years Sex: Male
SUBJECTIVE
CC:
The child mother reports,” My son has a strange cough that sounds like he is barking which worsens at night and has a hoarse voice. He is also experiencing difficulty in breathing.”
HPI:
The mother reports that the cough and hoarse voice started two days ago and had an abrupt onset. The cough has a barking characteristic and worsens at night. The cough is partially relieved by the intake of warm fluids. The mother also reports that the child has been having a hoarse cry, high body temperature, and production of light mucus. The child also has difficulty in swallowing and is unable to feed. There has been no history of swallowing a foreign material. She had administered the child with OTC paracetamol syrup to lower the body temperature and lower symptom, which was successful for some time, but the symptoms later recurred. Mother reports that the child’s immunization schedule is up to date.
Medications:
Paracetamol syrup to lower body temperature and relieve cough symptom.

PMH
Allergies:
No known food, environment or drug allergies.
Medication Intolerances:
No intolerance to drugs.
Chronic Illnesses/Major traumas
No history of chronic illnesses. No history of birth injuries or major traumas.
Hospitalizations/Surgeries

No history of hospitalization or surgery.
Family History
Chris is the 2nd born in a family of 2. Mother reports that the first born child has asthma. Mother and father have no history of chronic illnesses. Maternal grandmother has DM.

Social History
Lives with his parents in an urban town and has not yet enrolled to kindergarten. Mother reports that the child interacts well with family members and children his age.

ROS
General
Fever, lethargic, and inability to feed.
Cardiovascular
Reports difficulty in breathing. Denies bluish discoloration of lips and nails and edema.

Skin
Denies skin discoloration, bleeding, rashes or lesions. Respiratory
Reports a barking cough, difficulty in breathing. Denies hemoptysis, and wheezing. No history of TB or pneumonia.
Eyes
Corrective lenses, blurring, and visual changes of any kind
Gastrointestinal
Unable to feed.
Denies vomiting, diarrhea, constipation, or black tarry stools.

Ears
Denies hearing loss and ear discharge.
Genitourinary/Gynecological
Denies urinary urgency, frequency, change in urine color and discomfort when passing urine.