Focused Health History and Physical Assessment SOAP Note
Assignment Instructions: For this 4-5 page assignment, you will conduct a focused health history and physical assessment based upon your Practice Experience work in Shadow Health. Particularly, you will complete a focused assessment on Danny, a child who is complaining of a cough. Please submit your summary documentation in MS Word. Use the submission parameters and rubric below to guide you in completion of this written assignment. Submission Parameters: For this written assignment, please use the following guidelines and criteria. Also, please refer to the rubric for point allocation and assignment expectations. The expected length of the paper is approximately 4-5 pages, which does not include the cover page and reference page(s). Introduction (including purpose statement) Focus of the assessment Describe the focus of this particular assessment on the patient complaining of a cough Subjective Component Describe the ROS, PMH, and other relevant data in this section. Objective Component Describe the physical examination findings including techniques of examination Documented evidence to support clinical reasoning Describe the list of differential diagnoses Plan of care Describe the plan of care individualized to findings, life-span stage of development with culturally specific considerations for each focused area of assessment. Focused Health History and Physical Assessment SOAP Note. Conclusion References (use primary and/or reliable electronic sources) In regards to APA format, please use the following as a guide: Include a cover page and running head (this is not part of the 4-5 pages limit) Include transitions in your paper (i.e. headings or subheadings) Use in-text references throughout the paper Use double space, 12 point Times New Roman font Apply appropriate spelling, grammar, and organization Include a reference list (this is not part of the 4-5 pages limit) Attempt to use primary sources only. That said, you may cite reliable electronic sources (i.e. NCSBN, AANP)
Introduction
A cough is one of the most common presenting medical complaints that accounts for more than 30 million visits to primary healthcare providers annually in the United States. Coughs can range from mild to severe in terms of severity causing symptoms of urinary incontinence, vomiting, and even rib fractures. A cough refers to an innate primitive reflex of the immune system to safeguard against foreign objects. Patients who present with a cough that has lasted for less than three weeks is termed as an acute cough, if it has persisted for three to eight weeks it is considered subacute and if it has lasted for more than eight weeks, it is considered a chronic cough.Focused Health History and Physical Assessment SOAP Note
In this paper, the author discusses the subjective, objective, assessment, and management plan of a patient aged 8 years old with a cough complaint. Given the vagueness of the nature of cough as a symptom and its risk of an insidious underlying cause, lack of objective tools to conduct assessments, and a negative impact on the QoL, Nurse Practitioners (NPs) should evaluate patients presenting with the complaint of cough and treat it as an important issue.
The focus of the Assessment
This assessment focuses on an eight-year-old child who presented with the complaint of a cough. The author addresses the essential aspects of the presenting complaint through a detailed clinical history and thorough physical exam to make an accurate diagnosis and management plan. In the clinical history, the author focuses on the nature of the cough, the duration relieving and aggravating factors, and associated symptoms in the HPI (history of present illness). The physical exam assessment will incorporate the child’s vital signs, an inspection of the throat and nose for signs of postnasal drip or allergic rhinitis, an examination of the ears for wax foreign bodies or wax impactions which are associated with cough, inspection, palpation, percussion, and auscultation of the chest and lungs for deformities, the quality, nature, and symmetry of air entry and abnormal breathe sounds, vibrations caused by retained airway secretions, and fingers for finger clubbing.Focused Health History and Physical Assessment SOAP Note
Subjective Component
Chief Complaint-“I’ve been having a gurgly and watery cough for the last 5 days”.
HPI (History of Present Illness)-The patient presented with complaints of a 4-5 days cough that had a sudden onset. It was watery and gurgly and worsened at night making him stay awake the whole night leading to general fatigue. The cough is associated with right ear pain and a mild sore throat. Presently, he also has a running nose and frequent rhinorrhea. No reported aggravating factors, but the cough was relieved by an OTC cough medicine.
Medications: gummy dinosaur multivitamin, cough medicine (5 days)
Allergies: Cats, dust, NKDA
Past Medical and Surgical History: at seven years old, the patient reportedly suffered from pneumonia and was treated as an outpatient. He is up to date with all the immunizations apart from a flu vaccine that he has not had within the last 12 months. The patient received the hepatitis vaccine at 6 months, hepatitis A at 15 months, and the pneumococcal vaccine at 15 months. At 6 years, he received a DTaP vaccine, varicella vaccine, polio vaccine, and MMR vaccine.Focused Health History and Physical Assessment SOAP Note
Social History: the patient (Danny) is 8 years old in 3rd grade in an elementary school within the neighborhood. He likes skateboarding but does play sports. Danny acknowledges that he has a lot of friends but his best friend is Tony. He feels safe at home; he lives with his grandparents and parents. His primary caregiver, while his parents are at work, is his grandmother. Although they have Puerto Rican descent, they speak some Spanish at home although the primary language that they speak too often is English. Danny is often exposed to second-hand smoke since his father smokes cigars at home occasionally. The home environment is installed with working smoke detectors. Danny wears the seatbelt whenever he is in the car.
Family History: Danny’s mother was diagnosed with type 2 DM, obesity, hypercholesterolemia, hypertension, and spinal stenosis.
Father- is a chronic smoker with hypercholesterolemia and hypertension (HTN) and asthma in childhood.
Maternal grandmother- has type 2DM and HTN
Maternal grandfather- has eczema, and is a chronic smoker
Paternal grandfather-has no significant medical or surgical history and his paternal grandmother died at 52 years of age in an RTA (road traffic accident).Focused Health History and Physical Assessment SOAP Note
Review of Systems (ROS)
Constitutional: denies chills and fever, denies night sweats, feels fatigued most of the time
HEENT denies headaches, vision changes, nosebleeds, eye pain, and eye redness. He admits to frequent rhinorrhea, a running nose, a mild sore throat, right ear pain,
RS: denies DIB, chest tightness and chest pain, a gurgly and watery cough lasting 4-5 days, pain on inspiration.
Objective Component
Vital signs: BP 120/76mmHg, RR-28, O2 Sat 96% R/A, Temp 37.20C, spirometry- FEV1 – 3.15, FVC – 3.91 = 80.5%, PR-100.
General Exam: Danny is an 8-year-old patient of Puerto Rican descent who appears well-nourished and well developed for his age and is in no acute distress. He appears at the stated age, readily smiles, and has a pleasant look. His speech is clear and placed evenly. He is Alert and Oriented x4 spheres, cooperative and calm. He has no fever, weight loss, weakness, or chills.
HEENT: clear nasal discharge, redness and cobblestoning of the back of the throat. Dull eyes with pink conjunctivae, red and inflamed tympanic membrane of the right ear and the right cervical node is tender and enlarged.Focused Health History and Physical Assessment SOAP Note
Respiratory: the patient is stable with unlabored breathing. He has an increased respiratory rate but in no acute distress and can speak clearly and fluently in full sentences. On auscultation, there are clear breathe sounds, and bronchophony is negative. On percussion, the chest is resonant with an equal bilateral fremitus.
CVS: S1 and S2 are normal; there are no gallops, murmurs, or rubs.
Documented Evidence to Support Clinical Reasoning
Common cold (Acute nasopharyngitis) – the patient presented with complaints of a runny nose, productive cough, mild sore throat, rhinorrhea, and on examination, there was a clear nasal discharge.
Strep throat infection-the patient presented with complaints of sudden onset of a sore throat, rhinorrhea, cough, and fatigue. On examination, Danny had enlarged and tender cervical nodes, an inflamed and erythematous pharynx. To rule out this diagnosis, it will be important to order a rapid strep swab.
