NR 511 Week 3 SOAP NOTE Riley 18 Months
Subjective Chief Complaint Fever and Rash
Riley 18 months, male
Subjective
Chief complaint: fever and rash
History of present illness (HPI):
O: Onset-three days ago and is of normal levels in the morning then gets as high as 100 to 101
degrees in the afternoons.
L: Location— developed a red, diffuse rash to the torso and abdomen
D: Duration-three days
C: Characteristics/Associated symptoms- clear rhinorrhea in the last 24 hours. Rash that does
not itch and a barking cough in the last day. Not eating, not playing, minimal drinking.
m
er as
A: Aggravating factors-not discussed
co
eH w
R: relieving factors- temporary relief of coughing after robitussin for the cough, and tylenlol for
fever
o.
rs e
T: Treatments- Mother has stopped the Zyrtec. She is giving Robitussin cough and cold at 2.5 ml
ou urc
last night and this morning. Liquid Tylenol 7.5 ml last night and this morning.
S: Severity- Mother is very concerned about the level of the fever and the fact that after 3 days
he is not improving.
o
aC s
Past Medical History- Born at 34 weeks gestation via cesarean section, weight. 5 pounds 1
vi y re
ounce. The mother developed preeclampsia and gestational diabetes. The mother quit smoking
when she found out she was pregnant. Riley has allergies per mother and sometimes takes
Cetrizine syrup 2.5ml once daily, PRN congestion, and a children’s chewable multivitamin daily.
ed d
immunization history- Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months -
DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B
ar stu
Family History- They are maternal and paternal smokers. The mother has been one since age 22
at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases
is
reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of
hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated
Th
from Cuba in the 1970s. Tom has a history of hypertension, hyperlipidemia, and an MI with
stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the
age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the
Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving.
sh
Other family members died of old age. She is unaware of paternal familial health history.
Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Jo-
age 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather:
Tom-age 62
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, Social History- Both children currently live with their mother and maternal grandparents for the
last 8 weeks. Their father is involved but lives several hours away where he works.
Review of Systems:
Constitutional: fever
Neurologic: not reviewed
Head/Eyes/Ears/Nose/Mouth/Throat: rhinorrhea
Integumentary: red rash on torso and abdomen
Cardiovascular: not reviewed
Respiratory: barking cough
Genitourinary: urinating
m
Gastrointestinal: decreased appetite
er as
co
Musculoskeletal: not reviewed
eH w
Hematologic: not reviewed
o.
Endocrine: not reviewed rs e
ou urc
Objective
o
Vital signs: 18 months-height: 85 centimeters (83rd percentile), weight: 13 kilograms (83rd
aC s
percentile),
vi y re
Prior Visit: 13 months-height: 83 centimeters (98th percentile); head circumference: 48
centimeters (85th percentile), weight: 13.3 kilograms (98th percentile)
ed d
B/P: 90/54, T: 99.5, HR: 118 BMP/reg., Resp: 28, reg, non-labored, SpO2: 95%
ar stu
General: somewhat lethargic and cries some throughout exam. SKIN: Light erythema noted to
the cheeks bil. HEENT: Head normocephalic atraumiatic. Conjuctiva clear, non-icteric, but
mildly injected PERRL. Unable to complete fundoscopic exam. Tympanic membranes intact
is
with scant clear fluid posteriorly bil and mild injection. EAC unremarkable. Pinna/tragus w/o
tenderness. Nares patent, mucosa mildly injected, sl. edema in inferior and medial turbinates bil,
Th
moderate clear to milky rhinorrhea. Pharynx with mild slight erythema, tonsils 2/4 bil. Oral
exam unremarkable. Neck supple w/mild anterior cervical lymphadenopathy bil. Thyroid small,
firm, equal bil. CARDIOPULMONARY: Heart RRR w/o murmur. Lungs with mild expiratory
sh
wheeze throughout and barking cough noted occasionally throughout examination. Respirations
even and unlabored. Abdomen rounded normoactive bowel sounds throughout, soft, non-tender,
no masses or organomegaly.
Lab: WBC 9.0, Lymph 42%, Monocytes 7%, Neutrophils 50%, Eosinophils 2%, Hgb 13%, Hct
40
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Subjective Chief Complaint Fever and Rash
Riley 18 months, male
Subjective
Chief complaint: fever and rash
History of present illness (HPI):
O: Onset-three days ago and is of normal levels in the morning then gets as high as 100 to 101
degrees in the afternoons.
L: Location— developed a red, diffuse rash to the torso and abdomen
D: Duration-three days
C: Characteristics/Associated symptoms- clear rhinorrhea in the last 24 hours. Rash that does
not itch and a barking cough in the last day. Not eating, not playing, minimal drinking.
m
er as
A: Aggravating factors-not discussed
co
eH w
R: relieving factors- temporary relief of coughing after robitussin for the cough, and tylenlol for
fever
o.
rs e
T: Treatments- Mother has stopped the Zyrtec. She is giving Robitussin cough and cold at 2.5 ml
ou urc
last night and this morning. Liquid Tylenol 7.5 ml last night and this morning.
S: Severity- Mother is very concerned about the level of the fever and the fact that after 3 days
he is not improving.
o
aC s
Past Medical History- Born at 34 weeks gestation via cesarean section, weight. 5 pounds 1
vi y re
ounce. The mother developed preeclampsia and gestational diabetes. The mother quit smoking
when she found out she was pregnant. Riley has allergies per mother and sometimes takes
Cetrizine syrup 2.5ml once daily, PRN congestion, and a children’s chewable multivitamin daily.
ed d
immunization history- Birth – Hep B, 2 months – DTaP, COMVAX, PCV13, IPV, 4 months -
DTaP, COMVAX, PCV13, IPV, 6 months – DtaP, PCV 13, IPV, Hep B
ar stu
Family History- They are maternal and paternal smokers. The mother has been one since age 22
at one pack-per-day until 18 months ago. The father continues to smoke. There were no diseases
is
reported in either parent. Kayla has a history with gestational diabetes. Mary has a history of
hyperlipidemia, Type 2 DM, and Hypertension. They are Latin American in descent, emigrated
Th
from Cuba in the 1970s. Tom has a history of hypertension, hyperlipidemia, and an MI with
stenting 2 years ago. The mother has two siblings; one who died in an MVA 5 years ago at the
age of 18 a younger brother, and an older sister who is 42 and lives in a large urban city in the
Midwest with her family, and she is in good health but also had PCOS and difficulty conceiving.
sh
Other family members died of old age. She is unaware of paternal familial health history.
Field Family: Mother: Kayla-age 37, Father: Mike-age 39, Daughter: Lily-age 15, Daughter: Jo-
age 5, Son: Riley-age 13 months. Maternal Grandmother: Mary-age 55, Paternal Grandfather:
Tom-age 62
This study source was downloaded by 100000829244943 from CourseHero.com on 08-28-2021 04:40:24 GMT -05:00
https://www.coursehero.com/file/24108671/MMiller-Week3-SOAPdocx/
, Social History- Both children currently live with their mother and maternal grandparents for the
last 8 weeks. Their father is involved but lives several hours away where he works.
Review of Systems:
Constitutional: fever
Neurologic: not reviewed
Head/Eyes/Ears/Nose/Mouth/Throat: rhinorrhea
Integumentary: red rash on torso and abdomen
Cardiovascular: not reviewed
Respiratory: barking cough
Genitourinary: urinating
m
Gastrointestinal: decreased appetite
er as
co
Musculoskeletal: not reviewed
eH w
Hematologic: not reviewed
o.
Endocrine: not reviewed rs e
ou urc
Objective
o
Vital signs: 18 months-height: 85 centimeters (83rd percentile), weight: 13 kilograms (83rd
aC s
percentile),
vi y re
Prior Visit: 13 months-height: 83 centimeters (98th percentile); head circumference: 48
centimeters (85th percentile), weight: 13.3 kilograms (98th percentile)
ed d
B/P: 90/54, T: 99.5, HR: 118 BMP/reg., Resp: 28, reg, non-labored, SpO2: 95%
ar stu
General: somewhat lethargic and cries some throughout exam. SKIN: Light erythema noted to
the cheeks bil. HEENT: Head normocephalic atraumiatic. Conjuctiva clear, non-icteric, but
mildly injected PERRL. Unable to complete fundoscopic exam. Tympanic membranes intact
is
with scant clear fluid posteriorly bil and mild injection. EAC unremarkable. Pinna/tragus w/o
tenderness. Nares patent, mucosa mildly injected, sl. edema in inferior and medial turbinates bil,
Th
moderate clear to milky rhinorrhea. Pharynx with mild slight erythema, tonsils 2/4 bil. Oral
exam unremarkable. Neck supple w/mild anterior cervical lymphadenopathy bil. Thyroid small,
firm, equal bil. CARDIOPULMONARY: Heart RRR w/o murmur. Lungs with mild expiratory
sh
wheeze throughout and barking cough noted occasionally throughout examination. Respirations
even and unlabored. Abdomen rounded normoactive bowel sounds throughout, soft, non-tender,
no masses or organomegaly.
Lab: WBC 9.0, Lymph 42%, Monocytes 7%, Neutrophils 50%, Eosinophils 2%, Hgb 13%, Hct
40
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