NEURO SOAP GERIARTRICS
SUBJECTIVE:
ID: JT
Age: 11
Race: Caucasian
Gender: Female
Date of Birth: 11/27/12
CC: “My Right ear hurts”
HISTORY OF PRESENT ILLNESS (HPI): Came in with her parent and is a good historian. Pt is here for pain in her right ear. Onset: started 3 days ago, Location: Right Ear Duration: it's been hurting all the time, it started about 3 days ago Characteristic: “The pain is sharp and throbbing” Alleviating and aggravating factors: I have been swimming a lot at the pool. Radiation: “When I am sleeping it feels better”, “My mom put cotton in my ear, and it helped a little bit” Timing: “It has been hurting all the time” Severity: On a scale from 0-100 how would you rate your pain? “It would be an 8 or 9. Mother states has been taking Tylenol as needed
PAST MEDICAL HISTORY:
Tubes in Ears when pt was 3 years old
MEDICATIONS:
Tylenol 160mg tab as needed for pain
ALLERGIES: NKA
FAMILY HISTORY:
Mother-alive- age 35-no medical conditions
Father-Alive-age 37-no medical conditions
Sister-Alive-age 9-no medical conditions
SOCIAL HISTORY:
TOBACCO USE/Vaping: Denies ever smoking.
ALCOHOL USE: Denies ever drinking.
DRUG USE: denies ever using drugs.
HOUSING: Lives at home with parents and 1 sister
IMMUNIZATIONS:
Is current on all childhood Immunizations age: Hep B series DTaP: 1st, 2nd, and 3rd dose IPV: 1st, 2nd, and 3rd MMR: 1st dose VAR: 1st dose Hep A series
REVIEW OF SYSTEMS:
GENEAL: States overall feels good
HEENT: Denies difficulty hearing, a runny nose, denies having a sore throat. Pt reports pain in the right ear
RESP: no c/o of difficulty breathing denies any coughing.
CV: No complaints of swelling or problems
OBJECTIVE:
Vital signs:
Pulse: 101 beats per minute
Blood Pressure: 110/70 mmHg
RR: 18 beats/cycle
Temp: 98.10 F
SpO2 RA: 100%
Ht: 4”5 Wt: 53lbs
PHYSICAL EXAM:
HEENT: PERRLA, the sclera is white, the conjunctiva appears pink, and extraocular movements are intact; no signs of hemorrhage or exudate were observed. The external appearance of the ear is normal with no lesions, redness, or swelling. Right Tympanic membrane and inner ear display redness, with fluid noted behind the tympanic membrane, Ear Canal without redness or soreness. Hearing is normal, whisper test was performed. Both nares are open and clear, the septum is in the midline, and the mucosa appears pink and normal with no polyps or discharge. The oral mucosa is pink and moist; the pharynx shows no signs of erythema, exudates, or lesions. The left ear shows no signs of infection.
RESP: no respiratory distress, Even and unlabored, bilaterally clear to auscultation and percussion without rales, rhonchi, wheezing, or diminished breath sounds.
CV: Regular rhythm and rate, with normal sinus rhythm showing S1 and S2, sound without any abnormal murmurs, clicks, rubs, or gallops.
BUY SOAP NOTE ASSIGNMENT FROM EXPERTS
Differential Dx: (Gaddey et al., 2019)
- Acute otitis media (H66.9) Definitive Diagnosis
- Otitis media with effusion (H65.199)
- Cerumen impaction (H61.23)
The final diagnosis is acute Otitis media.
PLAN:
Diagnostic plan:
None
Pharmacological Treatment:
Amoxicillin 7ml BID for 10 days.
Tylenol 160mg 1 tab up to 4x a day and at bedtime for pain.
Referral:
No referrals at this time
F/U
Follow-up: Two weeks or earlier if symptoms worsen. This will give the child time to have completed the full cycle of antibiotics.
Education: (CDC, 2021)
Teach the importance of washing hands
Apply a warm compress (warm face cloth) to the ear.
Encourage the child to rest as much as possible
Side effects of antibiotics to look out for is nausea and diarrhea.
References:
CDC Childhood Injury Report. (2019, February 06). Retrieved from https://www.cdc.gov/safechild/child_injury_data.html
Gaddey, H, Wright, M, Nelson, T, 2019. Otitis Media: Rapid Evidence Review. Am Fam Physician. 2019;100(6):350-356. https://www.aafp.org/pubs/afp/issues/2019/0915/p350.html
CDC, 2021. Preventing and treating ear infections, a parent’s guide. https://www.cdc.gov/antibiotic-use/ear-infection.html
