i-Human Week #4 Full SOAP Note and Follow-Up Plan for an 18-Month-Old Pediatric Cough Case

I-HUMAN WEEK #4 FULL SOAP NOTE AND FOLLOW-UP PLAN FOR
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AN 18-MONTH-OLD PEDIATRIC COUGH CASE
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• Name:i Gradyi Turneri
• Age:i 18i monthsi
• Height:i 2i fti 10i ini (86i cm)i
• Weight:i 28i lbi (12.7i kg)i
• Reasoni fori Visit:i Coughi

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SOAP NOTE i i




Patient Information
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• Name:i Gradyi Turneri i i
• Age:i 18i monthsi
• Sex:i Malei
• Height:i 86i cmi
• Weight:i 12.7i kgi
• Accompaniedi by:i Motheri
• Chiefi Complaint:i Coughi

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, S — Subjective
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Chief Complainti i




Motheri reportsi thati thei childi hasi hadi ai coughi fori 3i days.i

History of Present Illness (HPI)
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18-month-oldi malei presentsi withi 3i daysi ofi coughi andi nasali congestion.i Motheri reportsi thei coughi
startedi graduallyi andi isi worsei ati night.i Shei describesi thei coughi asi dryi andi occasionallyi harsh.i
Childi alsoi hasi runnyi nosei andi mildi decreasedi appetitei buti isi stilli drinkingi fluids.i

Motheri denies:i

• Wheezingi
• Cyanosisi
• Severei breathingi difficultyi
• Vomitingi
• Diarrheai

Childi hasi hadi low-gradei feveri (100.4°Fi /i 38°C)i ati home.i Feveri respondsi toi acetaminophen.i

Childi remainsi playfuli buti slightlyi morei irritablei thani usual.i

Noi knowni sicki contactsi buti attendsi daycare.i

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Past Medical History
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• Noi chronici illnessesi
• Noi priori hospitalizationsi
• Noi historyi ofi asthmai

Birth History i i




• Fulli termi
• Vaginali deliveryi
• Noi complicationsi

Immunizations i




• Upi toi datei
Medications i