Episodic/Focused SOAP Note Template

Episodic/Focused SOAP Note Template

:

Initials: J.M.

Age: 11 years.

Sex: Male

Race: African American

S.

CC: Right Earache

HPI: The patient is an 11 year African American boy that has had right ear ache that has
occurred for the last two days. In a scale of 1 to 10, he rates the pain at 7. The pain is aggravated
upon sleeping with no related reliving factors. Other associated symptoms include feeling warm
on the skin.

Current Medications: The patient is on no medication concerning the problem at hand.

Allergies: There is no known food or drug allergy for the patient.

PMHx: the grandmother reports that the boy received all the vaccines as per the schedule stated
by the World Health Organization. The patient has no history of admission, a major illness, or
surgeries conducted on him.

Soc Hx: the boy is in grade 4, stays with the grandmother, who is a businesswoman. The
grandparents do not smoke cigarettes or take alcohol. In the family, the members usual observe
safety measures by wearing safety gears while playing within the home as well as putting on
safety belts while using vehicles. The family also enjoys supports system from the boy’s parents
who undertake various occupational roles from various countries. The boy likes and spends most
of his time swimming in the family pool.

Fam Hx: No known history of chronic illness in the family. Both parents and grandparents to the
boy are alive with no major chronic illnesses.

ROS:

GENERAL: positive for fevers and chills. No weight loss and negative for fatigue.

Cardiovascular: no edema on the extremities. No chest pains. No tingling sensations.

Integumentary: skin is dry and clean, there are no rashes, lesions, or bruises.

Respiratory: no coughs or wheezing. No difficulty in breathing.

Eyes: no use of corrective lenses.

Gastrointenstinal: No abdominal pain, no nausea, vomiting or diarrhea.

Ears: no discharge from the ear. Patient reports pain from the right ear. There are mild instances
of ringing in the right ear.

Genitourinary-no changes in urinary frequency and urgency.

Nose/Mouth/Throat

Patient reports no bleeding gums, no bleeding from the nose, no hoarseness of voice.

Musculoskeletal: no history of fractures or dislocation.

Neurological: no history of seizures or headaches.

OBJECTIVE

VS: BP-120/87, PULSE 99, RR 23 T 99.9 WT 48

HEENT: The head is normocephalic. No discharge from the eye with the pupils reacting to light.
Concerning ears, the patient is not able to hear well with the right ear. The patient has a swollen
tan. No discharge or bleeding from the canal. No nasal flaring. Full range of motion for the neck
and no swollen lymph nodes.

CARDIOVASCULAR: S1 and S2 heard. The heartbeat has a regular rhythm and rate.

RESPIRATORY: there are symmetrical chest movement and no difficulty in breathing.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. The bowel sounds are
heard on all the four quadrants.

GENITOURINARY: No burning on urination

NEUROLOGICAL: No headache or dizziness,

MUSCULOSKELETAL: No muscle or joint pain.

HEMATOLOGIC: No pallor or bleeding.

LYMPHATICS: No enlarged node.

PSYCHIATRIC: Not explored

ALLERGIES: No history of , hives, eczema, or rhinitis.

Diagnostic results:

Autoscopy-done. Needed for the determination of the state of the ear canal (Papadakis, McPhee
& Rabow, 2017). No discharge or bleeding from the ear.

Audiometry- Essential in the determination of the hearing function and establishment of any ear
loss. The audiometry showed slight hearing loss from the right ear.

MRI- Is key in visualization of the temporo-mandibular joint that can also lead to pain in case of
arthritis or infection (Papadakis, McPhee & Rabow, 2017). The MRI showed normal joint.

A.

Differential Diagnoses

Otitis externa. It is also referred to as swimmers ear. It refers to the bacterial or fungal infection
that originates from water exposure. It turns to be a likely diagnosis in this case since the boy had
a history of spending much time swimming in the pool. In this case, the ear canal is inflamed; the

pain may be severe with a modest reduction in hearing (Pontefract et al., 2018). There is no
dizziness due to the location of the impacted area.

Otitis media: it refers to the information of the middle ear. The inflammation can be due to
infection or occur with the middle ear being sterile. The infection occurs when the
microorganisms access the middle ear through the Eustachian tube. In sterile otitis media, there
is no pain with the production of sereus (Pontefract et al., 2018). Patient presents with hearing
loss and vertigo.

Ear cancer; it affects both internal and external ear. It causes pain and impairing hearing. It
spreads to other areas of the ear. It is a consideration in this case and can be ruled out from the
various presentations. It leads to ear pain that is on and off (Chan & Yom, 2018). The condition
also leads to bleeding. This will, however, be confirmed via the magnetic resonance imaging.

Ear wax: occurs in the case where the wax in the ear canal gets impacted, thus causing pain in
the ear. The consideration for this diagnosis is based on the presentation of the patients with pain,
which is also when the wax is impacted in the ear.

Temporomandibular joint infection or arthritis: In both instances, the problem with the joints
manifests in the form of pain as in the case of James. This diagnosis is, however, confirmed via
imaging that determines the disease processes in the joint (Papadakis, McPhee & Rabow, 2017).

P.

Ear toileting would be useful in the elimination of the ear content in the form of debris or
materials resulting from the ear infection (Albert & Blaire, 2017).

Upon the establishment of the causative agent, the patient can benefit from either local antibiotic
ear drop or oral antibiotics for systemic management of the infection. Ointments and
waterproofing may also be necessary for ensuring no more infection to the impacted ear.

For the pain, the patient can use analgesics such as ibuprofen 200mg tds or paracetamol 500mg
tds (Albert & Blaire, 2017). This will also be key in the reduction of the inflammation of the tan.

The grandmother will also be taught on the entire management. This would entail the adherence
to the prescribed medication, besides, there is also the need to come to the clinic for follow-up
upon the carrying out of all the requested diagnostic tests.

References

Albert, R. J., & Blaire, M. R. (2017). U.S. Patent No. 9,839,608. Washington, DC: U.S. Patent
and Trademark Office.

Chan, J., & Yom, S. S. (2018). Cancer of the Ear. In Handbook of Evidence-Based Radiation
Oncology (pp. 137-143). Springer, Cham.

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2017). Current and
treatment 2017. McGraw-Hill Education.

Pontefract, B., Madaras-Kelly, K., Nevers, M., Fleming-Dutra, K., & Samore, M. (2018,
November). 732. Description of Diagnoses and Antibiotic Management of Otitis Media
and Otitis Externa in Adults. In Open Forum Infectious Diseases(Vol. 5, No. Suppl 1, p.
S263). Oxford University Press.

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