CONPH NSG6340/NSG6440 Subjective, Objective,
Assessment, Plan (SOAP) Notes
Student Name: Christiane Costa Course: NSG6440
Patient Name: (Initials ONLY) Date: 08/29/24 Time: 1400
O.K.
Ethnicity: Black Age:13 Sex: M
SUBJECTIVE (must complete this section)
CC: “Persistent cough for weeks”
HPI: The patient is a 13-year-old Hispanic male presenting with a 2-week history of persistent coughing. The cough is
mostly dry and occurs more frequently at night. The patient reports that the cough worsens with physical activity. He
denies fever, chills, sore throat, or shortness of breath. He has had no recent sick contacts, and his family reports no
known allergies. There has been no improvement with over-the-counter cough medications.
Medications: Albuterol 2 puffs (90 mcg per puff) every 4 to 6 hours as needed for relief of asthma symptoms
Previous Medical History: Diagnosed with mild intermittent asthma 2 years ago. No prior hospitalizations
for asthma exacerbations.
Allergies: NKA
Medication Intolerances: None
Chronic Illnesses/Major traumas: Asthma
Hospitalizations/Surgeries: None
Developmental History: Meeting developmental milestones appropriately. Per parents, gross motor skills are age-
appropriate, demonstrated by the ability to run, jump, climb, and balance well. Fine motor skills are also developing
appropriately, including skills such as drawing, writing, using utensils, and manipulating small objects.
Surgeries: none
FAMILY HISTORY (must complete this section)
M: Alive- no hx
F: Alive- unknown
Social History : Lives at home with parents and two siblings. No smoking in the household. No pets. Active in school
sports.
REVIEW OF SYSTEMS (must complete this section)
General: Reports fatigue, denies night sweats, and weakness Cardiovascular: Denies syncope, edema, shortness of
breath, and cyanosis.
Skin: Denies rash or swelling Respiratory: Reports dry cough, no wheezing
reported, no shortness of breath.
Eyes: Denies any visual changes, eye drainage, or eye pain Gastrointestinal: Reports decreased appetite, denies
abdominal pain, spitting up/vomiting, diarrhea, and changes in
stool.
Ears/Nose/Mouth/Throat: Denies ear pain, Genitourinary/Gynecological: Denies
denies sore throat or nasal congestion increased
urine output, dysuria, and increased urinary frequency, Denies
foul urine and hematuria,
Nose/Mouth/Throat: Denies sore throat or Musculoskeletal: Denies weakness, restriction of
nasal congestion movement, joint swelling.
, Breast: Deferred Neurological: Denies abnormal activity, abnormal
movements, and changes in strength.
Heme/Lymph/Endo: Denies swollen glands, Psychiatric: Denies symptoms of depression, anxiety,
bruising, mood
bleeding, and edema. swings, hallucinations, delusions, or behavioral disturbances.
OBJECTIVE (Document PERTINENT systems only, Minimum 3)
Weigh H eight: BMI BP: Temp: 36.9 Pulse: 78 Resp: 18
t: 167.64cm : 10/70
68.04k 24.
g 2
General Appearance: Well-developed, well-nourished male in no acute distress.
Skin:, Cool, dry, no drainage present
HEENT:Pupils are equal, round reactive to light, extraocular movements are intact, vision grossly normal, tympanic
membranes clear, oral mucosa moist, nasal drainage present
Cardiovascular: Regular rate and rhythm characterized by clearly audible S1 and S2 heart sounds, no murmurs,
rubs,
or gallops.
Respiratory: Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal
Gastrointestinal: Abdomen is symmetrical and slim, soft, non-tender, no guarding or rebound tenderness, bowel
sounds present in all four quadrants
Breast: Deferred
Genitourinary: No CVA tenderness, bladder non distended
Musculoskeletal: Full ROM
Neurological: Alert and oriented to person, place, time, and situation. No focal neurological deficit observed
Psychiatric: Cooperative, appropriate mood and affect, responds appropriately
Lab Tests:
▪ COVID-19 Test: Negative
▪ Influenza Test: Negative
DIAGNOSIS (Minimum required differential and
presumptive Dx's, can
do more)
Differential Diagnoses Diagnosis
• J45.20 - Mild intermittent asthma, uncomplicated-
▪ J20.9- Acute bronchitis, unspecified is refers to a form of asthma characterized by
characterized by inflammation of the bronchial infrequent symptoms that occur two or fewer
tubes, typically presenting with a persistent days per week, with nighttime awakenings two or
cough and fever. Acute bronchitis often follows a fewer times per month. This type of asthma does
viral infection and may include symptoms such as not significantly interfere with daily activities, and
sputum production and chest discomfort (Zaitsev lung function typically remains normal between
et al., 2023).
episodes, with an FEV1 greater than 80% of the
predicted value. Exacerbations are generally mild
J06.9- Acute upper respiratory infection,
and short-lived (Porsbjerg, Melén, Lehtimäki, &
unspecified refers to a viral infection affecting the
Shaw, 2023). Management usually involves the
upper respiratory tract, including the nose,
use of a rescue inhaler, such as albuterol, on an
throat, and sinuses. Symptoms typically include a
as- needed basis without the need for daily long-
runny nose, sneezing, cough, sore throat, and
term control medication. Patients are advised to
sometimes fever. The condition is usually self-
