NURS 6521 SOAP Note Pediatric week 6

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Chief Complaint (CC): Barking cough History of Present Illness (HPI): Pt, RR, is a 3 year old female, Caucasian, that came in with c/o sore throat, barking cough at night, and nasal congestion. Sore... throat started x 5 days ago and barking cough that worsens at night x 5 days ago, and nasal congestion with productive sounding cough x 3 days ago. RR no longer c/o sore throat, and barking cough has subsided per mother and was better once she left window open in room to let cold air inside and gave child Motrin. Mother states RR now has nasal congestion and productive sounding cough with hoarseness in voice that she gives Zyrtec 2.5 ml orally for runny nose and works. Medications: Motrin as needed 5 ml, last used x 2 days ago. Zyrtec 2.5 ml orally once daily for the past 3 days. Multivitamin. Allergies: NKDA, NKA Past Medical History (PMH): Croup at 2 years old, Pneumonia last year. Past Surgical History (PSH): NO past surgical history OB/GYN History: (if applicable) N/A Personal/Social History: RR is active, age appropriate, met all milestones, eats fruits and vegetables each day 2-3 servings. Immunizations: 2, 4, 6 month immunizations DTap, HIB, Hep B, Polio, PCV, rotovirus. 12 month Hep A, MMR, Varicella, HIB, Polio, 15 month Dtap, 18 month Hep A. Family History: mother has SVT Hx of heart ablation, Father well, Brother is iron deficiency anemia sometimes. Maternal grandmother high bp, high cholesterol, anxiety. Maternal grandfather WPW, A fib, hx of 2 heart ablations. Fraternal grandmother fast heart beat, fraternal grandfather COPD from smoking [Show More]

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