Subjective, objective, assessment, and plan (SOAP) notes; physical examsS; history taking; head, eyes, ears, nose, and throat (HEENT); respiratory; and cardiovascular systems. This weeks content should be on OTITIS +++PLEASE USE THE TEMPLATE PROVIDED IN THE ATTACHMENT. THE SOAP NOTE HAS TO BE DONE ON OTITIS TEMPLATE IS ATTACHED TO THIS POST, AS WELL AS THE RUBRIC. PLEASE USE REFERENCES NO OLDER THEN 5 YEARS OLD

Heent Week 2 soap notes

Subjective: A 10-year-old child complains of pain in the left ear. Patient reports pain that started three days ago, and it has gotten worse ever since. Also, he reports feeling pressure inside his ear on the side affected and a decrease in hearing. The patient does not have a fever or chills.

The left ear canal appears reddened and swollen on physical examination. In addition, there is a yellowish discharge in the ear. It is difficult to see the tympanic surface due to swelling and discharge. Examining the right ear, there is no evidence of abnormality.

Assessment: Based on the patient’s symptoms and physical examination, the diagnosis is otitis media with effusion of the left ear.

Plan:

1. For 10 days, prescribe oral antibiotics to treat an infection.
2. Administer analgesics for pain relief.
3. Assist the patient in avoiding water contact with the affected ear.
4. Schedule a follow-up appointment in 2 weeks to re-evaluate the patient’s symptoms and to check for resolution of the infection.

References:

1. Rosenfeld RM, Shin JJ, Schwartz SR, et al. Updated clinical practice guideline for otitis media (includes effusion). Otolaryngol Head Neck Surg. 2016;154(1 Suppl):S1-S41. doi: 10.1177/0194599815623467
2. American Academy of Pediatrics, Subcommittee for Management of Acute Otitis Media. Diagnosis, treatment and prevention of acute Otitis Media. Pediatrics. 2004;113(5):1451-1465. doi: 10.1542/peds.113.5.1451.