D.R.

Focused Exam SOAP Note

ID: D.R., 8-year-old, Puerto Rican, Male

Subjective
CC: “I've been feeling sick. I have been coughing a lot and I feel kinda tired.”

HPI: D.R. presents to the clinic complaining of a persistent cough that started 4-5 days ago and
feeling fatigued. Denies being around anyone sick but endorses that he does not practice
adequate hand hygiene. Also reports that his father smokes cigars in the house infrequently but
does smell it "a little bit." He has difficulty sleeping due to his cough and reports that he cannot
stay asleep for long, contributing to his fatigue. Reports not getting the full eight hours he
normally does due to cough. Reports cough worsens at night, describing it as “gurgly and
watery." Reports nose clear nose drainage, no difficulty breathing. Reports feeling like he has to
cough every few minutes. Denies knowing what is making him cough.

Past Medical History: Pneumonia last year. Frequent ear infections as a child.

Past Surgical History: No surgical history.

Family History of disease:

Mother: Mother T2DM, HTN, Hypercholesterolemia, spinal stenosis, obesity.
Father: Father smoker, HTN, Hypercholesterolemia, Asthma as a child.
Maternal Grandmother: T2DM, HTN.
Maternal Grandfather: Smoker, eczema.
Paternal Grandmother: Deceased, MVA, age 52.
Paternal Grandfather: No known history.

Habits: During the check-up, the patient mentioned good grades in school. Denies playing sports
or traveling recently. Reports that he is generally active. He also stated that he has no pets at
home. Currently in elementary school (3rd grade) student, best friend is Tony. States that his
father smokes cigars, and his mom reminds him to smoke outside. Bilingual in English and
Spanish.

Medications: Cough suppressant (syrup), brand unknown, “one spoonful” for cough.
Daily multivitamin (gummy), brand unknown.

Allergies: No known allergies.

Review of Systems:
General: Appears fatigued but stable, talking without difficulty but coughing frequently.
HEENT: Reports sore throat, pain while swallowing, and pain. Denies itchy eyes, eye
pain, watery eyes, headaches, and dizziness. Denies vision difficulty. Denies ear
discharge, itchiness, pain, hearing loss, or tinnitus. Endorses nose discharge. Denies nasal
congestion, sinus pain, and sneezing.
Cardio: Denies chest pain and tightness.
 Resp: Denies difficulty breathing.
GI: Denies nausea, vomiting, diarrhea, abdominal pain, constipation, bloating, or change
in bowel habits.
GU: Denies difficulty with bladder and pain.
Hematologic/Lymphatic: Denies nosebleeds and bruising.
Allergic/Immunologic: Denies allergies.

Objective
Vital Signs: 120/76, HR 100, O2Sat 96%RA, RR 28, T 37.2
General: Pleasant, calm, cooperative, well nourished, in no distress. Alert and oriented x
4, normal mood and affect. Appears fatigued with frequent cough.
HEENT:
Head: Normocephalic, atraumatic, no visible or palpable masses, normal hair
distribution.
Eyes: Bilateral eyes with equal hair distribution, conjunctiva clear and injected,
anicteric sclerae, EOM intact, PERRLA, normal convergence, no edema or ptosis.
Ears: Equal shape bilaterally. External auditory canals clear without
inflammation. Right tympanic membrane erythematic, bulging. Left tympanic
membrane pearly grey. Positive light reflex bilaterally. No drainage. Denies
hearing changes, tinnitus, or vertigo. Right ear pain reported 3/10 on 0-10
numerical pain scale.
Nose: No external lesions, mucosa pink bilaterally. Septum midline. No pain with
palpation of maxillary and frontal sinuses. Clear discharge noted.
Throat: Mucous membranes moist, no mucosal lesions or wounds visualized.
Uvula midline. Posterior cobblestoning and redness. No posterior drainage noted.
Lymph Nodes: Right cervical lymph node enlarged with reported tenderness.
Cardiovascular: S1/S2 present without murmur, gallops, or rubs.
Respiratory: Lung sounds clear, all fields. Increased RR without acute distress.
Unlabored breathing. Chest wall symmetric and resonant. Expected fremitus equal
bilaterally. Negative bronchophony. FVC: 1.78L, FEV1 1.549L (FEV1/FVC: 87%).

Assessment/Differential: Diagnosis differentials include common cold, strep throat, allergic

rhinitis, and asthma based on abnormal findings affecting the ears, throat, and lymphatic region.

Plan:
 Referral to an allergist to test and rule out allergies.
 Lung function tests should be conducted to rule out asthma.
 Conduct strep culture to rule out strep throat.
 Initiate anti-tussive through topical ointment, Vicks VapoRub Children’s, to decrease
cough at night for adequate sleep.
 Increase fluid intake, and educate on frequent and proper hand hygiene and the need for
rest.
 Follow-up in one week if symptoms do not improve or worsen.

Rationale for Findings and Plan:

Danny Rivera presented to the clinic with a complaint of cough and fatigue. A thorough history
and physical examination were conducted to determine the potential diagnosis. Danny stated that
he had been experiencing a cough for five days that worsened at night, causing sleep disturbance
and daytime fatigue. Questions asked during the examination revealed relevant information
about the cough, including its onset, frequency, duration, characteristics, and aggravating and
relieving factors. Asking Danny about his current medication revealed that his mom gave him
over-the-counter cough medicine that morning. The purple cough syrup provided temporary
relief, but he continued to cough frequently throughout his assessment. Asking about his
symptoms, Danny mentioned having a runny nose with a clear discharge. While asking about
social habits, Danny confirmed that he had not been in contact with sick individuals but does not
practice adequate hand hygiene and touches his face frequently throughout the day. Asking if he
smokes revealed that he is exposed to secondhand smoke because his father smokes cigars in the
house sometimes.

During the physical examination, Danny’s nose produced a clear discharge. The back of his
throat showed redness and cobblestoning, while the tympanic membrane of his right ear was
inflamed. Palpation revealed swollen and tender lymph nodes on the right side of his neck.
Danny did not seem to be in acute distress despite an increased respiratory rate, and his breath
sounds were clear when his lungs were auscultated. Spirometer readings showed a result of 87%.

These findings suggest Danny may suffer from a common cold, strep throat, allergic rhinitis, or
asthma. Therefore, additional tests such as a strep throat test, allergen skin test, and blood work
may be necessary to reach a definitive diagnosis. The common cold causes nose, sinuses, and
airways symptoms, including congestion, coughing, sore throat, malaise, and fever. Symptoms
can appear within ten hours and peak after three days. Coughing may last up to three weeks
(Schapowal et al., 2019). A strep throat culture would help determine whether Danny’s
lymphadenopathy and sore throat are signs and symptoms of streptococcal or non-streptococcal
infection (Thai et al., 2018). An allergy skin prick test can help determine whether Danny has
allergies to common aeroallergens such as grass, weed, animal dander, etc. (Brown, 2019).

Although the spirometer test result of 87% and a pulse oximetry reading of 96% do not
definitively indicate asthma, Danny should be referred for a lung function test. Diagnosing
asthma, particularly mild asthma, is problematic in children when only considering standardized
guidelines (Saglani & Menzie-Gow, 2019). Children with stable respiratory diseases may have
normal spirometry results, even in cases of severe illness (Saglani & Menzie-Gow, 2019).

According to DeGeorge and colleagues (2019), the only established options that are safe and
effective treatments for common cold symptoms in children include the use of acetylcysteine,
nasal saline irrigation, intranasal ipratropium, and topical ointments with menthol, camphor, and
eucalyptus oils. Danny and his parents should be educated on stopping the use of the over-the-
counter cough syrup, and using a topical anti-tussive instead. It should be applied liberally to his
chest only because topical ointment containing camphor can lead to seizures if ingested. This
means always keeping it away from the face, including underneath the nostrils (DeGeorge et al.,
2019). Lastly, it is vital to advise patients on the significance of maintaining good hand hygiene
to prevent the spread of cold viruses.
 References

Brown, T. (2019). Diagnosis and management of allergic rhinitis in children. Pediatric Annals,
48(12), e485–e488. https://doi.org/10.3928/19382359-20191111-01

DeGeorge, K., Ring, D. J., & Dalrymple, S. N. (2019). Treatment of the Common Cold.
American Family Physician, 100(5), 281-289.
https://www.aafp.org/pubs/afp/issues/2019/0901/p281.html?wm=3049_b111

Saglani, S., & Menzie-Gow, A. N. (2019). Approaches to asthma diagnosis in children and
adults. Frontiers in Pediatrics, 7. https://doi.org/10.3389/fped.2019.00148

Schapowal, A., Dobos, G., Cramer, D., Chung Ong, K., Adler, M., Zimmermann, E., Brandes-
Schramm, J., & Lehmacher, W. (2019). Treatment of signs and symptoms of the common cold
using EPs 7630 - results of a meta-analysis. Heliyon, 5(11), e02904.
https://doi.org/10.1016/j.heliyon.2019.e02904

Thai, T. N., Dale, A. P., & Ebell, M. H. (2018). Signs and symptoms of group A versus non-
group A strep throat: A meta-analysis. Family Practice, 35(3), 231-238.
https://doi.org/10.1093/fampra/cmx072