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)

1. Acute otitis media (H66.9) Definitive Diagnosis
2. Otitis media with effusion (H65.199)
3. 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