Soap Week 3
R.F 17months old, F
S:
CC: Fever, rash, rhinorrhea and cough.
HPI: Riley is a 17month old male, brought in to the clinic by his mom due to fever as
high as 103,104F and rash to the torso and abdomen. Mother reports that Riley also has
rhinorrhea and cough. Mother reports that Riley is drinking, but not as well as usual. “He
did have a good wet diaper this morning, but is not really eating much and is not playing”
Fever:
Onset: a couple of days ago. Location: generalized. Duration: ongoing.
Characteristics: normal levels in the morning then gets as high as 103 to 104 degrees in
the afternoons. Aggravating Factors: not really eating much and is not playing
Relieving factors: none, not improving, after 3days. Treatment: Liquid Tylenol ½ a tsp
Rash:
Onset: 24hrs ago. Location: torso and abdomen, Duration: ongoing. Characteristics:
Red, diffuse rash to the torso and abdomen that does not itch. Aggravating Factors:
Riley is not really eating much and is not playing Relieving factors: unknown.
Treatment: none
Rhinorrhea:
Onset: a couple of days ago. Location: nose Duration: ongoing. Characteristics: clear
rhinorrhea cough. Aggravating Factors: Riley is not really eating much and is not
playing, has wet diaper. Relieving factors: Robitussin. Treatment: none
PMH: Born at 34weeks
, Current medications: Liquid Tylenol, Robitussin.
Surgeries: not given
Allergies: not given
Vaccination History: not given
ROS
Constitutional: Any weight loss, reports fevers or changes in activity level? (reports
some lethargy)
HEENT: Eyes: Any visual problem with Riley? Any puffiness to the eyes, any lines to
the eyelids, pain, redness, or discharge from the eyes? Any history of trauma to Riley’s
eyes?
Ears/Nose/Throat: Have you observed any hearing loss or changes in hearing in Riley?
Any ear pulling? Have you noticed any difficulty swallowing, any postnasal drip in
Riley?
Cardiovascular: Any shortness of breath, sweating, color changes with feeding, history
of murmur, fainting or dizziness?
Respiratory: reports cough, wheezing or SOB? Any respiratory problems at birth? Any
tachypnea, grunting, flaring, and retractions?
GI: Any nausea, vomiting or diarrhea? Any food allergies? Have you noticed Riley with
abdominal pain?
GU: How many wet diapers in the past twenty-four hours? Is he drinking as appropriate?
Reports inadequate drinking or eating.
Hematologic: Any abnormal bleeding? Easy bruising?
R.F 17months old, F
S:
CC: Fever, rash, rhinorrhea and cough.
HPI: Riley is a 17month old male, brought in to the clinic by his mom due to fever as
high as 103,104F and rash to the torso and abdomen. Mother reports that Riley also has
rhinorrhea and cough. Mother reports that Riley is drinking, but not as well as usual. “He
did have a good wet diaper this morning, but is not really eating much and is not playing”
Fever:
Onset: a couple of days ago. Location: generalized. Duration: ongoing.
Characteristics: normal levels in the morning then gets as high as 103 to 104 degrees in
the afternoons. Aggravating Factors: not really eating much and is not playing
Relieving factors: none, not improving, after 3days. Treatment: Liquid Tylenol ½ a tsp
Rash:
Onset: 24hrs ago. Location: torso and abdomen, Duration: ongoing. Characteristics:
Red, diffuse rash to the torso and abdomen that does not itch. Aggravating Factors:
Riley is not really eating much and is not playing Relieving factors: unknown.
Treatment: none
Rhinorrhea:
Onset: a couple of days ago. Location: nose Duration: ongoing. Characteristics: clear
rhinorrhea cough. Aggravating Factors: Riley is not really eating much and is not
playing, has wet diaper. Relieving factors: Robitussin. Treatment: none
PMH: Born at 34weeks
, Current medications: Liquid Tylenol, Robitussin.
Surgeries: not given
Allergies: not given
Vaccination History: not given
ROS
Constitutional: Any weight loss, reports fevers or changes in activity level? (reports
some lethargy)
HEENT: Eyes: Any visual problem with Riley? Any puffiness to the eyes, any lines to
the eyelids, pain, redness, or discharge from the eyes? Any history of trauma to Riley’s
eyes?
Ears/Nose/Throat: Have you observed any hearing loss or changes in hearing in Riley?
Any ear pulling? Have you noticed any difficulty swallowing, any postnasal drip in
Riley?
Cardiovascular: Any shortness of breath, sweating, color changes with feeding, history
of murmur, fainting or dizziness?
Respiratory: reports cough, wheezing or SOB? Any respiratory problems at birth? Any
tachypnea, grunting, flaring, and retractions?
GI: Any nausea, vomiting or diarrhea? Any food allergies? Have you noticed Riley with
abdominal pain?
GU: How many wet diapers in the past twenty-four hours? Is he drinking as appropriate?
Reports inadequate drinking or eating.
Hematologic: Any abnormal bleeding? Easy bruising?
