CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
Student Name: Ny’Teefa Hopkins Course: NSG6435
Patient Name: (Initials ONLY) M.R. Date: 03/18/2025 Time: 10:15
Ethnicity: Black/African American Age: 7 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: "She's been complaining of a cough, sore throat, and a headache. She has been laying around a
lot more than usual too."
HPI: Patient is a 7-year-old African American female in office with her mother for evaluation of flu-like
symptoms x 1 day. Patient’s mother reports that her fever started last night with a temperature of. Mother
reports patient also has symptoms of a cough, congestion, and body aches. Patient states she is very tired and
presents with lack of energy. She is drinking normally with normal voids. The patient’s mother has given
patient over-the-counter medications, children’s Tylenol and Motrin, at home but symptoms continue to persist.
Medications :
- Children’s Tylenol. Take 12.5 mL every 4 hours by oral route as needed. Do not give more than 5
times in 24 hours.
- Children’s Motrin chewable tablets. Chew 2 ½ tablets every 6 -8 hours by oral route as needed. Do not
use more than 4 times a day
Previous Medical History: No previous medical history
Developmental History:
Allergies: NKDA
Medication Intolerances: No 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: Hearing Screening - based on risk assessment: Parental concerns with child's
hearing: No and speech: No. Vision Screening - based on risk assessment: 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.
FAMILY HISTORY (must complete this section)
,M: Alive and well. No acute or chronic illnesses reported.
MGM: Alive and well. No acute or chronic illnesses reported.
MGF: Alive and well. No acute or chronic illnesses reported.
F: Alive and well. No acute or chronic illnesses reported.
PGM: Alive and well. No acute or chronic illnesses reported.
PGF: Alive and well. No acute or chronic illnesses reported
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, fatigue, and diminished activity level Cardiovascular: Denial of any chest pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of coughing and
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, sneezing Musculoskeletal: Denial of any joint
runny nose, and sore throat swelling. Reports body aches.
Breast: denial of any pai/tenderness Neurological: Denial of any weakness or
loss of consciousness
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
66 lbs. 2 oz 4 ft. 4.5 in 16.9 92/64 99.0 128 SPO2%: 96%
General Appearance: Patient is alert and lying down on the examination table. Patient is attentive and can
answer questions when asked.
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. No crusts/sores to nasal passages. Tonsils enlarged, no exudate noted. Normal
mucous membranes and pharyngeal erythema.
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 96% on room air. Nonproductive cough noted. Wheezing noted upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted with tenderness when moving joints
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, Strep testing performed.
Special Tests:
Albuterol Sulfate 2.5 mg/3 ml for inhalation 1 - 3cc vial x 1 treatment given.
Patient was found to have wheezing and coughing requiring handheld nebulizer treatment. Patient tolerated
well. After the treatment, the patient’s symptoms improved significantly.
, 112023 Page 1 of 2
CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)
Differential Diagnoses Diagnosis
• Diagnosis, (ICD 10 code and reference): • Presumptive diagnosis (ICD 10 code and reference):
- J10.1: (Influenza B) Influenza due to other - J09.X: Influenza due to identified novel influenza A
identified influenza virus with other respiratory virus.
manifestations (Cash, 2023) - R05.9: Cough, unspecified
• Diagnosis, (ICD 10 code and reference): - R06.2: Wheezing
- J20. 9 is the diagnosis code used for Acute - Symptoms of Influenza A include abrupt onset of fever,
Bronchitis, Unspecified (Cash, 2023) cough, sore throat, wheezing, rhinorrhea, headache,
• Diagnosis, (ICD 10 code and reference): body aches, altered mental status, tachypnea, joint
- B97. 4 Respiratory syncytial virus (Cash, 2023) pain, dehydration, febrile seizure, and extreme
irritability (Cash, 2023).
Plan/Therapeutics: Diagnostics:
1. Influenza A RAPID STREP GROUP A, THROAT
Patient positive for influenza A. Will treat with - Result: negative
prednisone. Encouraged to push fluids. Educated to RAPID INFLUENZA VIRUS A + B AND SARS COV + SARS COV 2
rotate Tylenol/Motrin for pain/fever AG PANEL, IA, UPPER RESPIRATORY SPECIMEN
Results:
Prednisolone 15 mg/5 mL oral solution - Flu A: positive
Take 5 mL every day by oral route for 5 days - Flu B: negative
Quantity ordered: 25mL - SARS-CoV-2: negative
2. Cough in pediatric patient
Will treat with Bromfed to help with cough
Bromfed DM 2 mg-30 mg-10 mg/5 mL oral syrup
Take 5 mL every 4-6 hours by oral route as needed.
Quantity ordered: 200mL
3. Wheezing
Wheezing noted upon visit. Patient treated with
nebulizer treatment. Will prescribe albuterol inhaler
with spacer for at home use.
Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler
Inhale 2 puff(s) every 4-6 hours by inhalation route as
needed.
Quantity: (1) 200 inhalation canister (ALBUTEROL
SULFATE HFA or equivalent)
SPACER WITH MASK - Use as directed. Qty: 1 Unit
112023 Page 2 of 2
, BMI:
6 Yr, 8 Mo = 15.8
7 Yr, 0 Mo = 16.8
7 Yr, 8 Mo = 16.9
Student Name: Ny’Teefa Hopkins Course: NSG6435
Patient Name: (Initials ONLY) M.R. Date: 03/18/2025 Time: 10:15
Ethnicity: Black/African American Age: 7 Sex: Female
SUBJECTIVE (must complete this section)
CC : Per mother: "She's been complaining of a cough, sore throat, and a headache. She has been laying around a
lot more than usual too."
HPI: Patient is a 7-year-old African American female in office with her mother for evaluation of flu-like
symptoms x 1 day. Patient’s mother reports that her fever started last night with a temperature of. Mother
reports patient also has symptoms of a cough, congestion, and body aches. Patient states she is very tired and
presents with lack of energy. She is drinking normally with normal voids. The patient’s mother has given
patient over-the-counter medications, children’s Tylenol and Motrin, at home but symptoms continue to persist.
Medications :
- Children’s Tylenol. Take 12.5 mL every 4 hours by oral route as needed. Do not give more than 5
times in 24 hours.
- Children’s Motrin chewable tablets. Chew 2 ½ tablets every 6 -8 hours by oral route as needed. Do not
use more than 4 times a day
Previous Medical History: No previous medical history
Developmental History:
Allergies: NKDA
Medication Intolerances: No 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: Hearing Screening - based on risk assessment: Parental concerns with child's
hearing: No and speech: No. Vision Screening - based on risk assessment: 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.
FAMILY HISTORY (must complete this section)
,M: Alive and well. No acute or chronic illnesses reported.
MGM: Alive and well. No acute or chronic illnesses reported.
MGF: Alive and well. No acute or chronic illnesses reported.
F: Alive and well. No acute or chronic illnesses reported.
PGM: Alive and well. No acute or chronic illnesses reported.
PGF: Alive and well. No acute or chronic illnesses reported
Social History:
REVIEW OF SYSTEMS (must complete this section)
General: Reported fever, fatigue, and diminished activity level Cardiovascular: Denial of any chest pain
Skin: Denial of any rashes or bruise. No report of trauma. Respiratory: Report of coughing and
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, sneezing Musculoskeletal: Denial of any joint
runny nose, and sore throat swelling. Reports body aches.
Breast: denial of any pai/tenderness Neurological: Denial of any weakness or
loss of consciousness
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
66 lbs. 2 oz 4 ft. 4.5 in 16.9 92/64 99.0 128 SPO2%: 96%
General Appearance: Patient is alert and lying down on the examination table. Patient is attentive and can
answer questions when asked.
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. No crusts/sores to nasal passages. Tonsils enlarged, no exudate noted. Normal
mucous membranes and pharyngeal erythema.
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 96% on room air. Nonproductive cough noted. Wheezing noted upon auscultation.
Gastrointestinal: No abnormalities visualized. Normal bowel sounds. No tenderness upon palpation. No
hepatomegaly or splenomegaly noted
Breast: No lumps or lesions. No nipple discharge.
Genitourinary: Clear, straw-colored urine.
Musculoskeletal: Full range of motion noted with tenderness when moving joints
Neurological: Cranial nerves grossly intact.
Psychiatric: Patient engaged in conversation. Speech is comprehensive.
Diagnostic Studies: Flu A&B, COVID, Strep testing performed.
Special Tests:
Albuterol Sulfate 2.5 mg/3 ml for inhalation 1 - 3cc vial x 1 treatment given.
Patient was found to have wheezing and coughing requiring handheld nebulizer treatment. Patient tolerated
well. After the treatment, the patient’s symptoms improved significantly.
, 112023 Page 1 of 2
CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes
DIAGNOSIS (Minimum required differential and presumptive dx's, can do more)
Differential Diagnoses Diagnosis
• Diagnosis, (ICD 10 code and reference): • Presumptive diagnosis (ICD 10 code and reference):
- J10.1: (Influenza B) Influenza due to other - J09.X: Influenza due to identified novel influenza A
identified influenza virus with other respiratory virus.
manifestations (Cash, 2023) - R05.9: Cough, unspecified
• Diagnosis, (ICD 10 code and reference): - R06.2: Wheezing
- J20. 9 is the diagnosis code used for Acute - Symptoms of Influenza A include abrupt onset of fever,
Bronchitis, Unspecified (Cash, 2023) cough, sore throat, wheezing, rhinorrhea, headache,
• Diagnosis, (ICD 10 code and reference): body aches, altered mental status, tachypnea, joint
- B97. 4 Respiratory syncytial virus (Cash, 2023) pain, dehydration, febrile seizure, and extreme
irritability (Cash, 2023).
Plan/Therapeutics: Diagnostics:
1. Influenza A RAPID STREP GROUP A, THROAT
Patient positive for influenza A. Will treat with - Result: negative
prednisone. Encouraged to push fluids. Educated to RAPID INFLUENZA VIRUS A + B AND SARS COV + SARS COV 2
rotate Tylenol/Motrin for pain/fever AG PANEL, IA, UPPER RESPIRATORY SPECIMEN
Results:
Prednisolone 15 mg/5 mL oral solution - Flu A: positive
Take 5 mL every day by oral route for 5 days - Flu B: negative
Quantity ordered: 25mL - SARS-CoV-2: negative
2. Cough in pediatric patient
Will treat with Bromfed to help with cough
Bromfed DM 2 mg-30 mg-10 mg/5 mL oral syrup
Take 5 mL every 4-6 hours by oral route as needed.
Quantity ordered: 200mL
3. Wheezing
Wheezing noted upon visit. Patient treated with
nebulizer treatment. Will prescribe albuterol inhaler
with spacer for at home use.
Albuterol sulfate HFA 90 mcg/actuation aerosol inhaler
Inhale 2 puff(s) every 4-6 hours by inhalation route as
needed.
Quantity: (1) 200 inhalation canister (ALBUTEROL
SULFATE HFA or equivalent)
SPACER WITH MASK - Use as directed. Qty: 1 Unit
112023 Page 2 of 2
, BMI:
6 Yr, 8 Mo = 15.8
7 Yr, 0 Mo = 16.8
7 Yr, 8 Mo = 16.9
