Pediatric Ear Pain: Episodic/Focused SOAP Note Week 5 NURSING ASSIGNMENTS SAMPLE Pediatric Ear Pain: A Comprehensive Episodic SOAP Note and Differential Diagnosis

Pediatric Ear Pain: Episodic/Focused SOAP Note Week 5 NURSING ASSIGNMENTS SAMPLE Pediatric Ear Pain: A Comprehensive Episodic SOAP Note and Differential Diagnosis

Solution

Episodic/Focused SOAP Note 

Patient Information:

Initials: A.M.                              Age: 3 years old                  Sex: Female               Race: White

S.

CC (chief complaint): “My daughter has a fever and complains of a hurting ear. She developed a cold about 3 days ago with sniffles, has a yellowish nasal discharge and a cough.”

HPI: Amy is a 3-year-old female patient who has been brought to the clinic accompanied by her mother. As reported by the mother, Amy developed a cold about 3 days ago, has a cough, and presents with yellowish nasal discharge. These symptoms started 3 days ago. She further indicates that she has not given her daughter any medications to reduce the pain.

Current Medications: None.

Allergies: No known drug or food allergies.

PMHx: All immunizations taken according to schedule. She was hospitalized due to malaria complications at the age of two years.
Soc Hx: Amy is physically active. Both parents deny alcohol or cigarette consumption.

Fam Hx: Both parents are alive with no serious health diagnosis. Grandparents are alive too. Maternal grandmother has type 2 diabetes.

ROS:

GENERAL:  Reports fever, denies abnormal weight loss.

HEENT:  Eyes: Denies blurred vision. Ears: Reports ear pain. Reports hearing impairment. Reports yellowish discharge from the ears. Nose: Reports a yellowish nasal discharge, reports sniffles. Throat: Reports a cough.

SKIN:  Denies itching or rash.

CARDIOVASCULAR:  Denies chest pain or chest discomfort.

RESPIRATORY:  Reports a cough. Denies shortness of breath. Reports a yellowish nasal discharge.

GASTROINTESTINAL:  Denies diarrhea, abdominal pain, or vomiting.

GENITOURINARY:  Denies urination-related issues.

NEUROLOGICAL:  Denies a headache or dizziness. Reports difficulty sleeping due to ear pain.

MUSCULOSKELETAL:  Denies joint pain, muscle ache, or back pain.

HEMATOLOGIC:  Denies abnormal bleeding or other blood-related disorders.

LYMPHATICS:  Denies abnormal enlarged nodes.

PSYCHIATRIC:  Denies history of any mental disorders.

ENDOCRINOLOGIC:  Denies reports of abnormal night sweats.

ALLERGIES:  Denies a history of food or drug allergy.

O.

VII. Physical examination

Vital signs: Respiratory rate: 18 breaths per minute, BP; 105/60, temperature; 104oF, pulse; 90 beats per minute, weight; 14.3 kg.

General appearance: Amy is unsettled. She is crying uncontrollably due to ear pain. She continues to cough while crying.

Skin: Absence of lesions, rashes, or sores. Warm and intact.

HEENT:

Head: No evidence of trauma or masses. It is normocephalic. No evidence of alopecia.
Eyes: Conjunctivae are clear. No evidence of hemorrhage.

Ears: The eardrum is swollen and erythematous. Yellow fluid is seeping from the ear. The tympanic membrane is dark-pink in color.

Nose: Septum is positioned midline. Nasal mucosa in moist, hairy, and pink. Evidence of a yellowish nasal discharge.

Throat: Absence of mouth lesions or sores. Throat is erythematous.

Neck: No swelling, thyroid is palpable.

Nodes: Absence of inguinal swelling.

Breasts: No discharge or abnormal masses.

Chest: Absence of rubs, wheezes, or rhonchi.

Heart: S1, S2. No murmur or gallop. PMI is visible. Absence of edema. Heart rhythm is normal.

Abdomen: No abdominal tenderness.

Back/spine: Absence of mobility challenges or deformities.

Extremities: Absence of tremor, joint tenderness, or swellings in all extremities.

Genitalia/Rectal: Absence of vaginal discharge or inflammation.

Neurologic:

Mental status: Lacks concentr