SOAP NOTE Acute Dermatitis: HPI: XX is a 3-year and 2-month-old female patient accompanied by a mother that reports the patient has…
Example SOAP Note
Date: 01/01/16
Patient Initials: XX
Gender: Female
Age:3 years 5 months
Chief complaint: Pain in right ear
HPI: XX is a 3-year and 2-month-old female patient accompanied by a mother that reports the patient has had mild cold-like symptoms including clear nasal secretions and a dry cough x 6 days. Mother has been using OTC remedies (Zarbee’s) and nasal saline suction with minimal improvement. Now x 2 days, patient is c/o pain to right ear, worse at night, that is causing disrupted sleep. Also reports fever x 1 yesterday of 101.7, irritability and poor appetite. No nausea, no vomiting, no diarrhea, no rash, no recent travel.
Allergies: No Known Allergies
Current Meds: OTC cold medications, no calcium supplements, no herbal supplements.
PMH: No significant medical history. No previous hospitalizations, no previous emergency room visits, no disability, no chronic illness, no abuse/neglect.
Surgical/procedural: No prior surgery.
Exposure: no exposure to contagious disease, no stings, bites, or scratches. No recent travel.
Environmental exposure: No second hand cigarette smoke exposure.
Dietary: Current diet normal for age. Contains grains, dairy, meats, fruits and vegetables.
Family Hx: Paternal grandfather with hypertension. Maternal grandmother with DM Type II.
No family history of asthma, no hepatitis, no history of cancer, no thyroid disorder, no arthritis, no psychiatric disorders, no HIV, No TB, no clotting factor deficiency.
Social History: Patient is cared for at home. Attends daycare 3 times/week.
Review of Systems:
General: Fever and irritability
EENT: Right ear pain, clear nasal secretions, denies eye symptoms, denies redness or discharge from eyes, denies neck symptoms
Oropharynx: Denies sore throat, denies dysphagia, denies excessive drooling, denies mouth sores
Pulmonary: Dry cough, denies shortness of breathe
Cardiovascular: Denies cardiovascular symptoms, denies palpitations, denies chest pain
GI: Poor appetite, denies diarrhea, denies vomiting, denies abdominal pain
GU/ genital: Denies dysuria, denies urinary frequency and urgency
Neuro: Denies headache, denies dizziness, denies LOC
Musculoskeletal: Denies muscular discomfort, denies difficulty with ambulation
Integumentary: Denies skin symptoms, denies rash
Vitals:
Temperature: 99 F
Pulse: 98 bpm
Respiratory Rate: 24 per min
BP: 89/59 mmHg
Height: 40 inches
Weight: 37 pounds
BMI: 69%
Pain: 4/10 (FACES scale)
Physical Exam:
General: Well developed, nourished and hydrated, no acute distress noted.
HEENT
Head: Normocephalic, no evidence of a head injury.
Eyes: Bilat – EOMs intact, PERRLA, no swelling or tenderness of eyelids, no hyperemia of conjunctiva, no eye discharge.
Ears:
Left ear: External auditory canal intact, no erythema, no edema, no discharge noted, tympanic membrane intact, no bulging, not retracted, no fluid behind TM, visible bony landmarks
Right ear: External auditory canal intact, bulging tympanic membrane noted with serous behind TM, erythematous, decreased translucency, loss of bony landmarks
Nose: clear nasal secretions noted, turbs not swollen, no sinus tenderness, no external nasal deformities.
Mouth: Lips symmetric, no abnormalities of tongue, no buccal mucosal abnormalities noted
Pharynx: Tonsils not enlarged, symmetric, no exudate, no erythema, uvula midline
Neck: No decrease in suppleness, no cervical mass was seen.
Pulmonary: Clear to auscultation bilat, equal expansion, no rales, no wheezing, no use of accessory muscles
Cardiovascular: No thoracic asymmetry noted. Heart rate and rhythm regular, heart sounds normal, no murmurs were heard, pulses equal, cap refill +2
Abdomen: Bowel sounds normoactive x 4, no palpable mass, no abdominal pain on palpation, no guarding, no distension, no HSM
Musculoskeletal: Active ROM in all extremities, no joint swelling noted
Neurological: Appropriate muscle tone, no abnormalities of balance and gait noted
Dermatologist: Good turgor, hydrated, no lesions, no rash
Psychological: No conditions noted.
Differential Diagnosis:
· Otitis Externa
· Foreign Body in Ear
· Mastoiditis
Assessment:
Pain, unspecified ICD 10: R52
Fever presenting with condition classified elsewhere ICD 10: R50.81
Acute serous otitis media, right ear ICD 10:H65.01
Other specified viral diseases ICD 10: B33.8
BMI pediatric,5 th percentile to less than 85 % for age ICD 10: Z68.52
Plan:
· Supportive care. Continue normal saline nasal suction to removal secretions.
· Start Amoxicillin 400mg/5ml susp (80 mg/kg/day divided BID). Give 10 ml PO q 12 hours x 10 days.
– Return to the clinic if condition worsens or new symptoms arise.
· Go to the emergency room if condition worsens
· Encourage PO fluid intake. Monitor hydration status.
· Give Tylenol/Motrin for fever/pain.
Counseling/Education
· Ear infections Instructions for Parent.
· Do the treatment with antibiotic until finish for the full 10 days and side effects of antibiotic given (diarrhea, vomiting, nausea).
· Advised to give patient probiotic while taking antibiotic, such as Culturelle OTC
· Maintain good hand hygiene.
*Here you would write a 2-3 paragraph explanation to support how you ruled out the differentials, how you reached your final diagnosis and treatment plan using references in APA format*
