Episodic/ Focused SOAP Note for a Child With Ear Infection.

Posted: December 17th, 2022

Episodic/ Focused SOAP Note for a Child With Ear Infection.

Episodic/ Focused SOAP Note for a Child With Ear Infection
CC: “Mild earache.”
HPI: This is an 11 year-old Caucasian boy brought in by the mother with a complaint of mild earache for the past two days. The pain is associated with insomnia and is not throbbing. According to the minor, the pain gets worse when he is going to sleep. The pain worsens at night and rhe minor rated it at 5/10 on the pain scale. He also gets low grade fever, although the mother has not taken the actual temperature using a thermometer. He has not been given any medication for the pain so far.Episodic/ Focused SOAP Note for a Child With Ear Infection.

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Current Medications: The child is currently not on any medications.
Allergies: He is also has no known allergies.
PMHx: James received all the immunizations required for a child. He has not had any major illness or hospital admission. However, he has been treated before for acute otitis media (AOM).
Soc Hx: James is the second born in a family of three. He comes from a middle class family amd goes to school.Episodic/ Focused SOAP Note for a Child With Ear Infection.
Fam Hx: No history of major illnesses in the family.
ROS: General: Low grade fever, normal weight for age, no fatigue. Well hydrated.
HEENT: Good vision with no discharge in the eyes. Ear: tympanic membrane dull. Nose unremarkable while throat shows enlarged adenoids.
Cardiovascular: Heart sounds normal.
Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain. Bowel sounds present.
Pulmonary: No labored breathing.
Neurological: Alert and oriented in all spheres.
O.
VS: P 78; R 20; T 37.7; Wt. 35kg; Ht 55”
General: The patient appears calm but is not active for a child of his age.
HEENT: the eyes and nose are unremarkable. Ears show a dull tympanic membrane with possible fluid behind it. Throat shows enlargement of adenoids.Episodic/ Focused SOAP Note for a Child With Ear Infection.
Cardiovascular: Heart aounds 1 and 2 are heard. He is not cyanosed and has no edema.
Gastrointestinal: Unremarkable. Symmetrical abdomen with audible bowel sounds.
Pulmonary: No crepitations, rhonchi, or rales on auscultation.
Diagnostic results: Otoscopy, Full blood count, and CXR. Otoscopy is the primary test for ear infections. The full blood count and CXR are needed to rule out any other pathological process that may be concomitant. Also, the full blood count serves to indicate the patient’s blood status in terms of Hb and whether there is leucocytosis indicating infection. Otherwise, a full blood count is a basic baseline test that all patients should undergo (Huether & McCance, and 2017). The chest X-ray is also a precautionary examination that provides a baseline radiograph for future comparison. It may also reveal presence of infection that was not yet obvious in the chest.Episodic/ Focused SOAP Note for a Child With Ear Infection.
A.
Differential Diagnosis:
1. Otitis media with effusion (OME)
2. Acute otitis media (AOM)
3. Chronic otitis media with effusion (COME)
4. Rhinosinusitis
5. Otitis externa.
Primary Diagnosis/Presumptive Diagnosis: Otitis media with effusion (OME).
The primary diagnosis of OME is made from the fact that James has a history of having been treated for acute otitis media. There is therefore a chance that it did not resolve completely. Also, on examination there is evidence of fluid behind the tympanic membrane (NIDCD, n.d.; Huether & McCance, 2017; Hammer & McPhee, 2014). AOM and COME are both closely related conditions, with unresolved AOM leading to both OME and COME. Rhinosinusitis can give symptoms similar to otitis because of the short nature of the Eustachian tube in children, while otitis externa is infection from the outside of the ear (NIDCD, n.d.; Huether & McCance, 2017; Hammer & McPhee, 2014; Katzung, 2018).

Patient Information:
Initials, Age, Sex, Race
S.
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:Episodic/ Focused SOAP Note for a Child With Ear Infection.
Location: head
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.Episodic/ Focused SOAP Note for a Child With Ear Infection.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.Episodic/ Focused SOAP Note for a Child With Ear Infection.
MUSCULOSKELETAL: No muscle, back pain, joint pain or stiffness.
HEMATOLOGIC: No anemia, bleeding or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.
ALLERGIES: No history of asthma, hives, eczema or rhinitis.
O.
Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)
A.
Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.Episodic/ Focused SOAP Note for a Child With Ear Infection.
P.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

Episodic/Focused SOAP Note Exemplar

Focused SOAP Note for a patient with chest pain

S.
CC: “Chest pain”

HPI: The patient is a 65 year old AA male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity. The pain is located in the middle of the chest and is accompanied by shortness of breath. The patient reports feeling nauseous. The patient tried an antacid with minimal relief of his symptoms.Episodic/ Focused SOAP Note for a Child With Ear Infection.

PMH: Positive history of GERD and hypertension is controlled

FH: Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.

SH : Negative for tobacco abuse, currently or previously; consumes moderate alcohol; married for 39 years

ROS
General–Negative for fevers, chills, fatigue
Cardiovascular–Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal–Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary–Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis

O.
VS: BP 186/102; P 94; R 22; T 97.8; 02 96% Wt 235lbs; Ht 70”

General–Pt appears diaphoretic and anxious
Cardiovascular–PMI is in the 5th inter-costal space at the mid clavicular line. A grade 2/6 systolic decrescendo murmur is heard best at the
second right inter-costal space which radiates to the neck.
A third heard sound is heard at the apex. No fourth heart sound or rub are heard. No cyanosis, clubbing, noted, positive for bilateral 2+ LE edema is noted.Episodic/ Focused SOAP Note for a Child With Ear Infection.
Gastrointestinal–The abdomen is symmetrical without distention; bowel
sounds are normal in quality and intensity in all areas; a
bruit is heard in the right para-umbilical area. No masses or
splenomegaly are noted. Positive for mid-epigastric tenderness with deep palpation.
Pulmonary– Lungs are clear to auscultation and percussion bilaterally

Diagnostic results: EKG, CXR, CK-MB (support with evidenced and guidelines)

A.
Differential Diagnosis:
1) Myocardial Infarction (provide supportive documentation with evidence based guidelines).
2) Angina (provide supportive documentation with evidence based guidelines).
3) Costochondritis (provide supportive documentation with evidence based guidelines).

Primary Diagnosis/Presumptive Diagnosis: Myocardial Infarction

Episodic/ Focused SOAP Note for a Child With Ear Infection.

P. This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
Episodic/ Focused SOAP Note for a Child With Ear Infection.