SOAP NOTE FOCUS: HEAD AND NECK

Name:

Institution:

Subjective 

Chief complaint: left earache 

History of present illness: Patient has had left earache for the last two days. The pain manifests as a constant, throbbing stabbing, rated by the patient as 7/10. Patient says the pain worsens when he blows his nose. The patient has had a cold with nasal congestion for a week, with nasal discharge being thick, tanned, and with sinus pressure. Present medications do not seem to have helped alleviate the pain. 

Medical history: the patient does not smoke or drink. He has had a recurrence of the condition in the past, but not for several years. The patient has not past surgical history. 

Social history: His patients are alive and well. The patient does not smoke; take illicit drugs, or alcohol.  The patient lives in a dorm. 

Medications – Nyquil, to help deal with the pain. 

Review of systems

Patient feels achy and tired. Temperature is normal (99 degrees Fahrenheit, within normal range).

Nasal passage is congested. The nose discharges a thick, tanned liquid. 

There has been no bleeding, nor pain apart from the ear. 

Mouth and throat: has a nonproductive cough. 

Respiratory: Patient has no sore throat. The patient denies any sob, or wheeze. The patient has no trouble breathing, no abdominal pain, and no burning with urination. 

Musculoskeletal: no joint pain, stiffness, or muscle pain hematologic: no bruising or bleeding. Feels fatigued and sore. 

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Mental health: denies depression and anxiety. 

Objective 

Vital signs measures: body temperature normal, blood pressure is at 120/80, heart rate at 71 per minute, respiratory rate at 17 per minute. 

Oxygen saturation – 100%. 

Height – 5’11”. Weight – 158lbs, BMI – 22.03. 

Eyelids without redness or swelling ears, no tenderness on palpation of tragus, no erythema or effusion. 

The tympanic membrane is red and bulging.

No ulcers noted. No foul odor from mouth, no tonsillar enlargement without exudates. The neck is supple without tender cervical nodes, no nuchal rigidity. The thyroid tissue firm is pliable and non-tender. Thorax and lungs: dry cough, respirations are unlabored, se of accessory muscles normal. No pain related to respiration. 

Assessment 

Diagnosis: Acute pain, due to the stabbing pain to the eardrum, caused by  bulging tympanic membrane, and put by the patient at 7/10. 

Differential Diagnosis: ineffective airway clearance, due to congested nasal passage. and insufficient knowledge (because the patient has had the same issue in the past, bus there is no history of him seeking treatment). 

Plan

The plan will be used to resolve the acute pain diagnosis.  

A prescription of ibuprofen, 200mg every six hours is given. This will help minimize the pain. 

Diphenhydramine, 25mg is given. This will resolve congested nasal passages. It will also resolve the sinus pressure. 

Education: the patient will be educated on the need to seek medical intervention fast, and on the means of preventing flu. 

Follow-up every two days to ensure compliance with medication, and to monitor efficacy of intervention.