NR509 Week 6 Cough SOAP Notes Template

Initials: DR: Age: 8 years old Gender: Male Height: 4’2” Weight: 90lbs BP: 120/91 HR: 100 RR: 28 FVC: 3.91 FEV1: 3.15 FEV1/FVC: 80.5% Temp: 37.2C SPO2: 96% Pain (1-10): 3 Allergies Medication: NKDA Food: No known food allergies Environment: No known environmental allergies History of Present Illness (HPI) Chief Complaint (CC): Cough Onset: 5 days ago Location: Chest Duration: Frequent (every couple of minutes without trigger noted) Characteristics: Wet, productive with clear sputum Aggravating Factors: Unknown triggers Relieving Factors: Cough medicine alleviated the cough for a short amount of time Treatment: Cough syrup today Current Medications Medication Dosage Frequency Length of Time Reason for Use Used Kids Multivitamin Gummies Recommended dosing Daily Unknown Health maintenance Cough Syrup Recommended dosing PRN Unknown Cough treatment