Please write a SOAP note for a 6‑year‑old child with a 2‑day history of cough, nasal congestion, sore throat, mild fever (peak 38.5 °C), exam showing temperature 38.3 °C, heart rate 100 bpm, respiratory rate 20/min, oxygen saturation 99% on room air, throat erythema without exudate, clear lungs, no cervical lymphadenopathy, immunizations up to date and no drug allergies.

SOAP Note: 6-Year-Old with Upper Respiratory Tract Infection

Subjective

• Chief Complaint: Cough, nasal congestion, and sore throat for 2 days
• History of Present Illness: 6-year-old child presents with 2-day history of cough, nasal congestion, and sore throat. Parent reports fever with peak temperature of 38.5°C at home. No difficulty breathing, no ear pain, no vomiting or diarrhea.
• Past Medical History: Immunizations up to date
• Allergies: No known drug allergies
• Review of Systems: As per HPI; otherwise negative

Objective

• Vital Signs:

  • Temperature: 38.3°C
  • Heart Rate: 100 bpm
  • Respiratory Rate: 20/min
  • Oxygen Saturation: 99% on room air

• Physical Examination:

  • General: Alert, interactive, well-hydrated, no distress
  • HEENT: Throat shows erythema without exudate or tonsillar enlargement; nasal mucosa congested with clear discharge; tympanic membranes normal bilaterally
  • Neck: No cervical lymphadenopathy
  • Lungs: Clear to auscultation bilaterally, no wheezing or crackles
  • Cardiovascular: Regular rate and rhythm, no murmurs

Assessment

Acute viral upper respiratory tract infection (common cold)

This is a self-limiting viral illness that does not require antibiotic therapy. 1 The clinical presentation—2-day duration of cough, congestion, sore throat with low-grade fever, clear lung examination, and absence of purulent nasal discharge or severe symptoms—is consistent with a viral URI rather than bacterial sinusitis, streptococcal pharyngitis, or acute otitis media.

Key diagnostic reasoning:

• Not bacterial sinusitis: Symptoms have been present only 2 days (bacterial sinusitis requires persistent symptoms ≥10 days, worsening symptoms after initial improvement, or severe symptoms with fever ≥39°C and purulent discharge for ≥3 days) 1
• Not streptococcal pharyngitis: Throat erythema without exudate, no tonsillar enlargement, no cervical lymphadenopathy, and presence of cough/congestion suggest viral etiology; rapid strep testing not indicated 1
• Not acute otitis media: Normal tympanic membranes on examination
• Expected course: Symptoms typically persist for at least 10 days in school-aged children 2

Plan

1. No Antibiotic Therapy

Antibiotics are not indicated and should not be prescribed for this viral condition. 1 Antibiotic use in viral URI provides no benefit and increases risk of adverse events including diarrhea, rash, Clostridium difficile colitis, and antibiotic resistance.

2. Symptomatic Management

• Fever/discomfort: Acetaminophen or ibuprofen as needed for fever >38.5°C or discomfort (dose by weight)
• Hydration: Encourage adequate fluid intake
• Nasal congestion: Saline nasal drops/spray as needed
• Avoid OTC cough and cold medications: These products are not effective and should be avoided in children under 6 years of age due to lack of proven efficacy and potential toxicity 3

3. Parent Education

• Expected duration: Symptoms typically last 10+ days; this is normal for viral URI 2
• Fever management: Fever is part of the body's immune response; treat for comfort, not to eliminate fever entirely
• Return precautions: Seek immediate care if child develops:
  • Difficulty breathing or rapid breathing
  • Persistent high fever (≥39°C) for >3 days
  • Worsening symptoms after initial improvement
  • Ear pain
  • Symptoms persisting beyond 10 days without improvement
  • Decreased activity, poor fluid intake, or decreased urination
  • Severe headache or neck stiffness

4. Follow-up

• Return visit or telephone follow-up in 10 days if symptoms persist
• Earlier return if any warning signs develop

5. School/Daycare

• May return to school/daycare when fever-free for 24 hours without fever-reducing medication and child feels well enough to participate

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Common pitfall to avoid: Do not prescribe antibiotics for "just in case" or parental pressure. The diagnosis of viral URI is clear, and antibiotic use will cause harm without benefit 1.