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Review the Rubric for more Guidance

Demographics

Chief Complaint (Reason for seeking health care)

History of Present Illness (HPI)

Allergies

Review of Systems (ROS)

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Nutrition:

Sleep/Rest:

LMP:

STI Hx:

Vital Signs

Labs

Medications

Past Medical History

Past Surgical History

Family History

Social History

Health Maintenance/ Screenings

Physical Examination

General:

HEENT:

Neck:

Lungs:

Cardio

Breast:

GI:

M/F genital:

GU:

Neuro

Musculo:

Activity:

Psychosocial:

Derm:

Diagnosis

Differential Diagnosis

ICD 10 Coding

Pharmacologic treatment plan

Diagnostic/Lab Testing

Education

Anticipatory Guidance

Follow up plan

Prescription

See Below (scroll down)

References

Grammar

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________

Date: _______________

RX ______________________________________

SIG:

Dispense: ___________ Refill: _________________

No Substitution

Signature:____________________________________________________________

SOAP

Demographics

Patient (A.R.) is a 5-year-old white Hispanic male.

Encounter Date: 03/37/2025

Chief Complaint (Reason for seeking health care)

Per mother “My son has been coughing and has had a runny nose for three days.”

History of Present Illness (HPI)

As per mother’s report, the patient’s coughing and runny nose has an onset of 3 days ago. The present illness is located within the upper respiratory tract. The duration of the patient’s symptoms is persistent. Symptoms include a dry cough with nasal congestion and rhinorrhea. Symptoms are aggravated at night and can be relieved with warm fluids and honey that reportedly help a little bit. The timing of the symptoms is intermittent throughout the past three days but consistent overnight. Severity of the symptoms are mild to moderate, but mother reports that her son has thankfully not had any difficulty breathing.

Allergies

As per the mother the patient has no known drug, environmental, food, herbal, and/or latex allergies.

Review of Systems (ROS)

General: Mother admits a low-grade fever (100.2°F) noted yesterday; no chills or night sweats.

HEENT: Mother admits the patient has congested nasal passages, clear rhinorrhea, dry throat, and mild ear discomfort.

Neck: Mother denies swelling or stiffness of the neck.

Lungs: Mother admits occasional dry cough, no wheezing or shortness of breath.

Cardio: Mother denies palpitations or chest pain.

Breast: Mother denies any breast tissue abnormalities with the patient.

GI: Mother denies nausea, vomiting, diarrhea, or constipation.

M/F genital: Mother denies any perineal abnormalities.

GU: Mother denies dysuria or frequency changes.

Neuro: Mother denies headaches, dizziness, or altered mental status.

Musculo: Mother denies joint or muscle pain.

Activity: Mother admits patient has slightly decreased energy level due to illness.

Psychosocial: Mother admits patient is well-adjusted, no behavioral concerns.

Derm: Mother denies any rashes or skin changes.

Nutrition: Mother admits the patient’s appetite has slightly decreased.

Sleep/Rest: Mother admits the patient is restless at night due to nasal congestion.

LMP: N/A

STI Hx: N/A

Vital Signs

BP: 98/62 mmHg in a sitting position

HR: 91 bpm

RR: 23 breaths/min

Temp: 99.8°F axillary

SpO2: 98% on room air

Weight: 21.2kg

Height: 113cm

CDC percentile 79.4%

Pain: 0 using the FACES scale

Labs

None reviewed at this time; clinical diagnosis based on symptoms.

Medications

Acetaminophen 160 mg oral solution every 4-6 hours as needed PRN for fever.

Ocean Nasal Spray sodium chloride nasal spray, 1 spray(s), nasal, as needed PRN for nasal congestion

Past Medical History

No significant major/chronic medical history

No history of asthma or respiratory conditions

No history of traumas or hospitalizations

Past Surgical History

No past surgical history

Family History

Mother: Endometriosis

Father: Hypertension

Older brother: Hypothyroidism

Maternal grandfather: Type II diabetes

Social History

Patient lives in a single-family home with stairs, with his mother, father, and older brother. Current living situation does not expose the patient to tobacco use and/or smoke, drug use, or alcohol use. Currently attends kindergarten in a public elementary school. Work status: N/A. Sexual orientation: N/A. Sexually active: N/A. Contraceptive use: N/A.

Health Maintenance/ Screenings

Comprehensive physical exam

Routine visual screening

Routine auditory screening

Height and weight for growth chart

Up to date on vaccinations, including the flu vaccine.

Physical Examination

General: Well-nourished, alert, interactive

HEENT: Head normocephalic, pupils 3mm regular and reactive, no auditory issues, mild nasal congestion, clear rhinorrhea, erythematous pharynx, no exudates, tympanic membranes clear.

Neck: No lymphadenopathy, no stiffness or lumps noted.

Lungs: Clear to auscultation bilaterally, no wheezing or crackles, chest rise is equal bilaterally

Breast: N/A due to lack of breast tissue.

Cardio: Regular rate and rhythm, no murmurs, rubs, or gallops.

GI: Soft, symmetric non-tender abdomen, normoactive bowel sounds

M/F Genital: not examined.

GU: unremarkable

Neuro: Alert and oriented, no focal deficits, cranial nerves intact

Musculo: Normal range of motion, no joint swelling

Psychosocial: appropriate mood given feeling slightly uncomfortable due to congestion.

Derm: No rashes or lesions noted, no cuts, growths, or irregular moles.

Diagnosis

Acute viral upper respiratory infection (URI)

Differential Diagnosis

Allergic rhinitis

Early sinusitis

Strep pharyngitis (less likely due to lack of exudates and high fever)

ICD 10 Coding

J06.9 – Acute upper respiratory infection, unspecified

Pharmacologic treatment plan

Acetaminophen 160 mg / 5 mL oral suspension, 5mL by mouth every 4-6 hours as needed for fever. Average cost is $14. Educate parent on importance of not exceeding daily dose limit (Thibault et al., 2023).

Ocean Nasal Spray – sodium chloride nasal spray, 1 spray(s), nasal, as needed PRN for nasal congestion. Average cost is $8. Educate parent to try not to use the spray for more than 3 days in a row as rebound rhinitis can occur (Štanfel et al., 2022).

Diagnostic/Lab Testing

Respiratory Pathogen Panel (RPP): negative result.

Education

Strategies to manage illness:

1) Educate the parent on the importance of rest and sleep for the patient, emphasizing how this can impact the recovery process. Encourage frequent naps to allow time for the body to heal.

2) Provide education on proper hygiene and etiquette while the patient is sick, emphasizing proper sneezing technique as well as the importance of handwashing.

3)Familiarize the parent with symptoms to look out for that may indicate a sign of illness, such as a cough, sore throat, or fever. Encourage the parent to communicate if symptoms worsen or new ones appear (Smith et al., 2023).

Self-management methods on healthy behaviors:

1) Emphasize importance of keeping the patient hydrated with clear liquids and warm broths. Nutrient dense meals will help support and boost the immune system.

2) Reinforce regular handwashing after coughing, sneezing, or touching the face with soap and water.

3) Educate the parent on gradually introducing physical activity back into the child’s routine once the child is feeling better.

Anticipatory Guidance

Primary prevention:

Hand hygiene, age-appropriate education on how to sneeze, cover their mouth, and use tissues.

Review immunizations and ensure patient stays on track with required vaccines for their age, including annual flu vaccine.

Advocate for a well-balanced diet that can support a healthy immune system.

Secondary prevention:

Inform mother to monitor for signs of complications and expect symptoms to resolve within 7-10 days, if this does not occur further medical evaluation is necessary (Smith et al., 2023)

Reinforce the need for annual visual and auditory screenings for the up-coming visit to keep track of the child’s development.

Follow up plan

Re-evaluation in 1 week if symptoms persist or worsen.

Immediate follow-up if fever >100.4°F for more than 3 days or signs of respiratory distress develop (Geppe et al., 2023)

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: A.R. Age 5

Date: 03/27/2025

RX Acetaminophen 160 mg/5 mL oral suspension

SIG: Take 5 mL by mouth every 4-6 hours as needed for fever.

Dispense: 120 mL Refill: no

No Substitution

Signature: