Focused SOAP Note
Student Name and clinical course: ______________________ ID:
Client’s Initials*:__J.P_Age___10__ Race: Latino__Gender: M Date of Birth_2-9-2012
Insurance ______None_________ Marital Status___Single_____
Subjective:
CC: I have an Ear Ache for the past 2 days
HPI: JP is an eight year old Latino male who came to the clinic complaining about having an ear ache that has been developing in regard of severity for the past two days. The patient also reported that the ear ache mostly intensified when he is asleep. The patient has also stated that due to the infection it is difficult for him to hear. During the assessment, it was discovered that the patient has a prominent tan on his skin, which also meant that it is evident he had been spending a majority of his free time swimming. It was also found that the patient pain is located in the ear canal.
Current Medication: Methylphenidate (5mg) which he has been using for the past 6 months.
Allergies: food- peanuts, environment – none, medication- none.
Past Medical History:
No past medical problem history was found in the patient.
Preventative care: Not applicable
Surgeries: No surgeries done to the patient.
Hospitalizations: Patient has never been hospitalized
LMP, pregnancy status, menopause, etc. for women: Not applicable to the patient.
Allergies:
No allergies reported to the patient.
Medications: Currently using Methylphenidate (5mg)
Family History: Mother is alive and is a heavy smoker, father alive not past medical complication, grandmother alive with diabetes, grandfather alive with arthritis
Also Read: Buy Nursing Soap Note Writing Help Online
Social History:
-Sexual history and contraception/protection – Not applicable
-Chemical history (tobacco/alcohol/drugs) – Not applicable
Other: Patient is an introvert and is often found with ear pods playing video games or music in his phone.
ROS
Constitutional: Itchiness and discomfort in the ear canal, the condition is made worse due his tendency to use ear pods and swimming.
Eyes: Normal
Ears/Nose/Mouth/Throat: Occasional hearing loss, nose normal breathing, normal for mouth and throat
Cardiovascular: No issues or problems with the chest
Pulmonary: No issues
Gastrointestinal: Reports vomiting and diarrhea on occasion
Genitourinary: No issue
Musculoskeletal: No issue
Integumentary & breast: No issue
Neurological: Reports headache and lack of sleep..
Unlocked Contain Properly Formatted PDF
SUBSCRIBE TO VIEW FULL SAMPLE
Now subscribe to get access to our juicy content FREE-of-CHARGE
Psychiatric: Not assessed
Endocrine: No issue
Hematologic/Lymphatic: Denies bleeding in the ear
Allergic/Immunologic: None documented
Objective
Vital Signs: HR: 82 BP: 112/78 Temp: 95 RR 22 SpO2 : 96 Pain 9/10 Height: 1.5m Weight: 45 BMI: 15.2 percentile
Labs, radiology, or other pertinent studies:
Otoscopy conducted
Physical Exam
The patient appeared to be highly anxious though his energy was low, perhaps due to the fact that he had not been sleeping because of the pain (Mayo Clinic, 2021). After conduct the physical examination, it was clear that the patient spent most of his time in the pool while also playing video games after swimming which was evident by the tar found in his ear and the significant redness that appeared on his outer ear in addition to a mild swelling on his tender lymph nodes.
Assessment
Based on the patient symptoms and lab results, it can be concluded that the patient had a case of otitis Externa, which is an ear infection condition most common with swimmers (Chung et al., 2018). The infection is usually caused by the extensive periods that one spends within the swimming pool which leads to the water creating a bacterial infection.
Differentials:
Otitis Externa (ICD-10 code H60.4) – This is a condition most common to swimmers, also referred to as the swimmer’s ear. The condition is caused by the patient spending too much time in the swimming pool causing water to remain on the patient ears developing a moist environment that causes bacteria (Mayo Clinic, 2021). This was the main diagnosis based on the fact that there was present of tar or thick fluid in the patient ear and the redness in his outer ear.
Otitis Media (ICD-10 code H66. 9): This was the second diagnosis because this condition is mostly found in children of the patient’s age, they are mostly infected by the condition due to colds and flu (Peterson & Reintjes, 2016). However, this was dismissed as the patient did not have these symptoms.
Myringitis (ICD-10- H73. 009): This was the third diagnosis as the patient complained of ear pain, however, the symptoms of Myringitis include fever for which the patient did not have (Chung et al., 2018).
Plan (4 pronged-plan for each problem on the problem list)
Otitis Externa:
1. Polymyxin B, neomycin, and hydrocortisone 3 to 4 drops to the affected ear four times a day.
2. Clean Ears with towel after swimming sessions
3. Antifungal ear drops – this can treat an underlying fungal infection
4. Maintain ear hygiene
Otitis Media:
1. amoxicillin-clavulanate 125 mg orally once a day
2. Clean Ears with towel after swimming sessions
3. Antifungal ear drops – this can treat an underlying fungal infection
4. Maintain ear hygiene
Myringitis:
A. amoxicillin-clavulanate 125 mg orally once a day for 30days
B. Clean Ears with towel after swimming sessions
C. Provide antifungal medication
D. Maintain ear hygiene
Follow up
Follow up will be done after 1 week
References
Chung, J., Lee, D. Y., & Kim, Y. H. (2018). Management of Myringitis: Current concepts and review. The Laryngoscope, 128(9), 2157-2162. https://doi.org/10.1002/lary.27179
Mayo Clinic. (2021, June 23). Ear infection (middle ear) – Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/ear-infections/symptoms-causes/syc-20351616
Peterson, S., & Reintjes, S. (2016). Otitis externa, otitis media, and mastoiditis. Oxford Medicine Online. https://doi.org/10.1093/med/9780199976805.003.0011