NURS 6512 Week 9 Pediatric SOAP Note Example

Focused Pediatric SOAP Note: Six Months of Nighttime Cough and Exercise-Related Wheeze in a 5-Year-Old Boy

Student Name

College of Nursing, Walden University

NURS 6512: Advanced Health Assessment and Diagnostic Reasoning

Instructor Name

Month Day, Year

Subjective

The child described here is an illustrative composite created for teaching, and nothing in this note comes from a real patient or a real chart. T.M. is a 5-year-old boy brought by his mother, who is the historian, for what she calls 'a cough that never really goes away.' She reports a dry cough that wakes him 4 to 6 nights per month for the past six months, worse between 0200 and 0400 and after he runs at recess or plays outdoors in cold air. Daytime cough or chest tightness occurs about three days per week. He was seen at urgent care three months ago, given a nebulized bronchodilator, and improved within 20 minutes. He now uses an albuterol inhaler without a spacer three to four times per week, with relief lasting a few hours. He has missed two school days this month, and his mother sleeps in his room when the cough is bad.

He was born at 39 weeks by vaginal delivery, with no neonatal intensive care stay, no intubation, and no home oxygen. He had one respiratory syncytial virus illness at 11 months managed at home without hospitalization. Eczema appeared at 18 months and still flares in winter, and he sneezes and rubs his eyes every spring. His newborn screen was normal, and he has had no pneumonia, no sinus surgery, and no choking episode. Medications are albuterol as described and an over-the-counter antihistamine on some nights; he takes no controller medication and has no known drug allergies. His father has asthma and his mother has allergic rhinitis. He lives with both parents and an indoor cat, sleeps on carpet in a home built in 1968, and a grandmother who visits weekly smokes outside. Immunizations are current, including influenza this season.

Development and daily function are otherwise unremarkable. He attends kindergarten, speaks in full sentences, dresses himself, and meets the milestones his mother reports, with no concern raised by his teacher (Hagan et al., 2017). His appetite is good, his stools are normal, and his weight has tracked the same curve since age 2. The focused review of systems is positive for cough, wheeze audible to his mother at night, nasal congestion, itchy eyes, and dry patches behind the knees. It is negative for fever, night sweats, weight loss, chest pain, vomiting after meals, sudden choking, foul-smelling stools, recurrent ear or skin infections, and any exercise limit other than the cough. There is no snoring, no daytime mouth breathing, and no hoarseness.

Objective

Weight is 19.5 kg at the 55th percentile, height is 111 cm at the 60th percentile, and body mass index is 15.8 at the 52nd percentile, all tracking the curves recorded at ages 3 and 4. Vital signs are temperature 98.4 F, heart rate 96, respirations 22, blood pressure 96/58, and oxygen saturation 97 percent on room air. He is alert, playful, and speaks in full sentences without pausing for breath. Infraorbital creases and a transverse nasal crease are present. The nasal mucosa is pale and boggy with clear discharge, and the posterior pharynx shows a cobblestone appearance without exudate. Tympanic membranes are normal bilaterally. The skin shows dry, thickened patches in both antecubital fossae, without excoriation, weeping, or signs of infection.

The chest is symmetric, with no increased anteroposterior diameter and no digital clubbing. There are no retractions, no nasal flaring, and no accessory muscle use at rest. Air entry is good and equal bilaterally. On quiet breathing the lungs are clear, but forced expiration produces a prolonged expiratory phase with scattered end-expiratory wheeze at both bases, and the same finding returns after he runs the length of the hallway for 60 seconds. There are no crackles, no focal decrease in breath sounds, and no stridor, which matters because a unilateral finding would move the reasoning toward a retained foreign body (Ball et al., 2023). Cardiac examination shows a regular rate and rhythm, normal first and second heart sounds, no murmur, and capillary refill under two seconds.

Objective testing was matched to his age. Spirometry was attempted with coaching across three efforts, and he could not produce reproducible flow-volume curves, which is expected below about age 6 and was recorded rather than left blank (National Heart, Lung, and Blood Institute, 2020). A Childhood Asthma Control Test completed with his mother scored 16 of 27, below the cutoff of 19 that marks inadequate control. Pulse oximetry was 97 percent before and after the hallway run. No chest radiograph, sweat chloride test, or allergy panel was obtained at this visit, and the reasons for that appear in the plan rather than being left to inference.

Assessment and Plan

The working diagnosis is asthma, mild persistent, with an allergic phenotype, alongside allergic rhinitis and atopic dermatitis. Asthma is the commonest chronic condition of childhood in the United States, which makes the base rate high and the discipline of the differential more important rather than less (Centers for Disease Control and Prevention, 2024). Three elements support the diagnosis together rather than singly: a symptom pattern that is episodic, nocturnal, and provoked by exercise and cold air; a documented response to a bronchodilator; and a variable expiratory finding on examination (Global Initiative for Asthma, 2023). Severity in a child aged 5 to 11 is graded before controller treatment begins. This child has symptoms about three days per week, awakenings 4 to 6 nights per month, rescue use three to four times per week, and two missed school days, which places him in the mild persistent range rather than the intermittent one (National Heart, Lung, and Blood Institute, 2020).

Four alternatives were carried and tested against the same findings. Recurrent viral-induced wheeze is the leading competitor at this age, but it clusters with colds and remits between them, while this child wheezes with exercise and cold air in the absence of infection. Allergic rhinitis with postnasal drip does produce chronic cough and is present here, yet it explains neither the exercise trigger nor the bronchodilator response, so it is a contributor rather than the diagnosis (Dains et al., 2020). Gastroesophageal reflux was considered because it causes nocturnal cough, but there is no relation to meals, no vomiting, and no worsening when he lies down after eating. A retained foreign body is the diagnosis that must never be missed, and it is unlikely across a six-month course with no choking event and symmetric, non-focal findings. Cystic fibrosis earned one sentence: it is not supported, since growth is on track, stools are normal, and the newborn screen was negative.

The plan begins with a controller and a teachable device. At this severity for ages 5 to 11, a daily low-dose inhaled corticosteroid with an as-needed short-acting bronchodilator is the recommended step, so fluticasone propionate 44 mcg, one inhalation twice daily through a valved holding chamber, is started, with albuterol 90 mcg, two inhalations as needed through the same chamber (National Heart, Lung, and Blood Institute, 2020). Spacer technique was demonstrated and repeated back by mother and child, since inhaler misuse explains more treatment failure than drug choice does. Trigger work is specific: the cat leaves the bedroom, bedding is washed weekly in hot water, no one smokes in the home or car, and an intranasal corticosteroid is started for the rhinitis. A written action plan with green, yellow, and red zones goes home and to school. Follow-up is in 4 to 6 weeks with a repeat control test, and referral to pediatric pulmonology if control has not improved.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2023). Seidel's guide to physical examination: An interprofessional approach (10th ed.). Elsevier.

Centers for Disease Control and Prevention. (2024). Most recent national asthma data. U.S. Department of Health and Human Services. https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm

Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care (6th ed.). Elsevier.

Global Initiative for Asthma. (2023). Global strategy for asthma management and prevention. https://ginasthma.org/reports/

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.

National Heart, Lung, and Blood Institute. (2020). 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (NIH Publication No. 20-HL-8140). U.S. Department of Health and Human Services.