Running Head: SOAP NOTES - CROUP 1

Soap Notes – Croup

Name:

Grade Course:

Tutor’s Name:

Date of Submission:
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Patient Information

Initial and Age: N. K.; Age: 5 years old; Gender: Male; Race: Caucasian

SUBJECTIVE:

Chief Complaint (CC): A parent bringing a patient for well-child assessment with barking

cough.

History of Present Illness (HPI): The mother stated that N. K. is a 5-year-old male, Caucasian

and presents the following signs: nasal congestion, barking cough, and sore throat. The nasal

congestion with productive sounding cough started 4 days ago, the barking cough started 4 days

ago but intensified 2 days ago, and sore throat started 6 days ago. The condition of N. K.

improved slightly when he was given Motrin for three days and the windows left open for the

most part of the day to allow free circulation of air in the room. The barking cough and sore

throat had subsided, but the productive sounding cough and nasal congestion with hoarseness in

voice has persisted despite administering the patient with Zyrtec 2.5 ml orally.

Medications: Motrin as needed 5 ml, last administered one day ago. Zyrtec 2.5 ml administered

orally once every day for the past four days. All these medications are over the counter (OTC)

non-prescriptions.

Past Medical History (PMH):

Allergies: NKA, NKDA

Childhood Illness: Pneumonia at three years, and Croup at 2.5 years.

Surgery: The mother denies any past surgical history on the patient.

Hospitalization: The mother denies any past hospitalization of the patient

Obstetric/Gynecologic: N/A

Psychiatric: N/A

Health Maintenance:

Immunization status: The mother confirmed that the patient received immunization against

DTap, HIB, Hep B, Polio, PCV and roto virus at 2nd, 4th, and 6th month, MMR, and Hep A at 12th

month, Polio, HIB, and Varicella at 15th month, and Hep A at 18th month.

Dental Examination: The mother confirmed that the patient goes for dental check once a year

and he has no any known dental problem.

Last eye examination: The mother confirmed that the last eye examination was two years ago

and the results showed normal functioning of the eyes.

SBE/Pap/Gyn: None

Testicular/Rectal examination: None

Family History: The mother is having heart condition termed as SVT Hx which is caused by

heart ablation. The father is heathy and does not have any known diagnosed illness or condition.

The elder brother was diagnosed with deficiency of iron which sometimes results to anemic

episodes. The mother grandmother was diagnosed with anxiety, high cholesterol, and high blood

pressure. Mother grandfather also have heart condition which resulted from hx of 2 heart

ablations. He also has A fib, and WPW. The paternal grandmother has been diagnosed with high

pulses cause by fast heart beat rate. The paternal grandfather suffers from COPD which caused

by heavy smoking.

Personal and social history:

Education level: The mother stated that the patient attends the local elementary school in her

housing district. He has just completed her second year of preschool, and will be starting

kindergarten next year.

Personal interest: The mother states that N. K. is an active child, his growth and development is

appropriate with the age. He meets all the milestone activities that relates with his age.

Lifestyle (Exercise and Diet): The mother confirmed that the patient likes engaging in outdoor

activities such as playing soccer and riding bicycle. In terms of diet, the mother confirm that the

patient eats balanced diet, which is a combination of protein, carbohydrates, dairy, vegetables

and fruits every day with 2-3 servings.

Older adults: N/A

Review of Systems:

General: child’s eyes are slightly reddish and watery. He is not fatigued, acts normal and eats

normal.

Skin: The skin is normal with no rashes and well nourished. The mother states that N. K. once

suffered from diaper rush which left him with dark spots despite using Beadreux cream on the

affected area.

HEENT: Pt c/o stuffiness in nose and has cough with productive sounds, but the cough is dry.

The mother confirmed that the patient’s nasal drainage is clear. When the patient talks, there is

slight hoarseness in voice.

Breast: N/A

Neck: N/A
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Respiratory: Barking cough which started six days ago, subsided after administering medication

and turned into regular cough that sounds wet, and no mucus coughed up.

Cardiovascular: The mother denies any known diagnosed history of cardiovascular condition.

Gastrointestinal: The mother denies changes in patients’ eating habit. No known history of GI

conditions.

Genitourinary: The mother denies any known history of GU injuries or conditions. No known

diagnosed condition associated with bladder functioning.

Musculoskeletal: The mother states that no known history of MS condition or illness, and the

patient can ride a bike, and comfortably skip the rope.

Psychiatric: The mother stated that N. K. is a well-behaved child and does not get into trouble.

At home he interacts well with his siblings. She further states that no known behavioral and

psychological concern with school and home. During the night, the patients sleeps about 7-10

hours uninterrupted. When given games, he can play and follow the rules without any difficult.

Integumentary/Heme/Lymph: The mother states that no known history of lymphatic or

hematological condition as well as integumentary concerns.

Immunologic/Allergic: The mother denies any known or diagnosed immune deficiencies as

well as allergies.

Objective Data:

Physical Examination:
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Vital signs: Blood pressure per manual cuff on right upper arm in resting position is 96/64;

oxygen saturation at room air 97 %; non-labored respirations at rate of 23; oral temperature in

Fahrenheit 98.2 degrees; pulse 95 and regular.

Weight: 43 lbs / 20.7 kg equating to 80.3rd percentile

Height: 42 in. / 108.6 cm equating to 50th percentile

BMI: 16.8, equating to 88th percentile. This is an indication that the child is just above the

normal weight.

General: The patient is age appropriate, follows commands, walks straight and steadily, stay

close to his mother, not shy when I talk to her, happy but look a bit exhausted, well groomed, has

redness slightly around eyes, and looks healthy.

Skin: Negative for rashes; positive for sores, and bites. Also positive for dark spots due to healed

diaper rash.

HEENT: Heads feels normal in shale, eyes are red around but no vision changes, tympanic

membrane visible with slight bulging bilaterally, nasal turbinates red and swollen bilaterally with

nasal drainage, throat is slightly red, post nasal drip visible, and tonsils slightly swollen.

Neck: Lymph nodes appears slightly swollen

Lungs/Chest: Chest expansion equal Heart/Peripheral Vascular; heart sounds normal; positive

for s1 and s2; negative for gallop or skipped beats; negative for stridor in throat, and lung sounds

clear.

Heart/Peripheral vascular: Positive of regular rhythm and rate with negative of murmur,

gallop or rub; the peripheral and central pulses are palpable at 2+, negative of any edema.
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Musculoskeletal: Patient moves all extremities well; full ROM with negative limitation noted.

Psychological: Positively identify four different colors; speech is comprehensible and logical in

flow; patient was not shy with communication and was pleasant in interaction.

Neurological: Deep tendon reflexes are 2+/no clonus; normal tone throughout; gait is steady;

able to follow simple command, and is AAO x 4.

Assessment:

Priority Diagnosis: Pharyngitis which is associated with symptoms such as hoarseness in his

voice and past diagnosed with croup, which is one of the primary causes of pharyngitis (Ivaska,

et al., 2015). The primary diagnosis would be croup because of the barking cough and stridor

sounds when breathing.

Differential diagnosis for J02.9 Pharyngitis:

- J02.0 Streptococcal Pharyngitis

- B34.8 Rhinovirus

- J03.80 Tonsillitis

Upper Respiratory Infection: Because the patient has cough, redness in eyes, runny nose, and

nasal congestion, URI could be the other cause of N. K. condition (Zeng, et al., 2014).

Plan:

Lab Testing: A swab the throat to establish whether it is strep bacteria, if the results are

positive, the patient will be given Amoxicillin 250 mg oral suspension to take twice daily for

seven days (Kim, et al., 2018). If the results turn out to be negative, the patient will be given
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plenty of fluids, cough syrup such as ZArbees, honey, and Motrin to control inflammation and

pain.

Non-pharmacological: Eating balance diet, daily exercise, washing hands thoroughly and

observing good hygiene in school and at home.

References

Ivaska, L., Niemela, J., Vuorinen, T., Waris, M., Rantakokko-Jalava, K. & Peltola, V. (2015).

Viral and Bacterial Etiology of Acute Pharyngitis in Children. Infectious Disease Society

of America, 2(1): 1769.

Kim, G. E., Suk, W. S., Hee, J. C. & Bo, G. C. (2018). Clinical Presentation of Croup in

Children According to Causative Viruses. Allergy, Asthma & Respiratory Disease, 6(6):

290-294.

Zeng, L., Zhang, L., Hu, Z., Ehle, E. A., Chen, Y., Liu, L. & Chen, M. (2014). Systematic

Review of Evidence-based Guidelines on Medication Therapy for Upper Respiratory

Tract Infection in Children with AGREE Instrumeny. PLoS One, 9(2): e87711.