NR509 SOAP Note WEEK 7
Initials: Danny Age: 8 Gender: male
Height Weight BP HR RR Temp SPO2 Pain Allergies
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120/
76
100 28 37.2C 96% RA Med
...
NR509 SOAP Note WEEK 7
Initials: Danny Age: 8 Gender: male
Height Weight BP HR RR Temp SPO2 Pain Allergies
Click
or tap
here
to
enter
text.
Click or
tap
here to
enter
text.
120/
76
100 28 37.2C 96% RA Medication: none
Food: none
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) c/o cough, runny nose, right ear pain,sore throat CC is a BRIEF statement identifying
why the patient is here - in the
patient’s own words - for instance
"headache", NOT "bad headache for 3
days”. Sometimes a patient has more
than one complaint. For example: If
the patient presents with cough and
sore throat, identify which is the CC
and which may be an associated
symptom
Onset Cough, runny nose-5 days ago, right ear pain and sore throat since yesterday
Location Right ear, chest, throat, nose
Duration Reports constant cough and runny nose for 5 days day and night, keeps him
awakw at night. States sore throat/ right ear pain are constant since yesterday
Characteristics Reports a clear wet, gurlgy persistent cough, worsening at night, but not with
lying flat. Denies chills, fever, bodyaches or weakness,but states he is tired
since onset of cough, mild sore throat without difficulty swallowing, right ear
pain and a persistent clear runny nose. Denies nausea, vomiting or diarrhea,
shortness of breath or trouble with deep breathing. Denies decrease in
acitivties, or appetite.
Aggravating Factors Nothing makes it worse- denies knowing any triggers.
Relieving Factors Moms pruple cough medicine this morning
Treatment Purple cough medicine this am.
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication
(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time
Used Reason for Use
Purple Cough Syrup 1 dose once One time cough
OTC multivitamin 1 pill daily Unknown “ for health”
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