5 yr old female patient presents to the clinic with left ear pain and fever X 2 days.

She has been

irritable, crying and not eating.
A. Write a SOAP note of a hypothetical case of the above presentation.
B. Document detailed HEENT PE on your SOAP note.

Chief Complaint (CC): Left ear pain and fever

History of Present Illness (HPI): 5-year-old female presents to the clinic for left ear pain and
fever X 2 days. Mother states, “she has been irritable, crying, and not eating for the past 2 days.”
Mother stated, “fever does not go over 101 F.” Her appetite was fine and was eating fine until 1-
2 days ago. Her energy is good and her mother has no other concerns. No swelling or redness to
the area. Has been taking Tylenol with some relief in fever and pain. No recent falls or trauma.
Past Medical History (PMH): She has no major illness/problems to date.
Disabilities: none
Illnesses: none
Surgeries: none
LMP/OB: n/a
Hospitalizations: none
Trauma: none
Medications: Tylenol 240mg every 4-6 hours, no more than 5 does/day
Allergies: none
Immunizations: up to date
Exercise/Leisure: n/a, baby can walk, run, and jump
Sleep: 8-9 hours a night
Diet: traditional American food
Safety measures: wears sunscreen
Family/Social History: In kindergarten, no afterschool activities, lives at home with Mother,
Father, and older brother, no smokers in home, no safety concerns at home, no TB or lead risk
factors, sits in a 5-point harness car seat
Mother: 32 years old, healthy
Father: 34 years old, healthy
Grandmother: passed at age 81 years old, healthy
Grandfather: passed at age 82 years old, hyperlipidemia
Sibling: 1 brother 8 years old, healthy
Review of Systems (ROS)
General: fever x2 days, denies recent weight loss/gain, change in appetite/not eating as usual
Skin: Denies rash/lesions
HEENT: Guarding left ear, runny nose. Denies difficulty hearing, mouth sores, and sore throat
Resp: Denies wheezing, coughing, and dyspnea
CV: Denies cyanosis, swelling, erythema of skin
GI: Denies constipation, abdominal pain, nausea/vomiting, and diarrhea
GU: Denies difficulty urinating
MS: Denies falls or trauma
Neuro: Denies syncope, seizures, and tremors
Endocrine:
Psych: Difficulty sleeping

Objective Data
Vital Signs: Temp 37.5C, BP 108/60, HR 105, RR 24, O2 100% RA, Ht. 3’5” Wt. 40 lbs BMI:
16.7 85th percentile, pain 2/10 Wong-baker faces pain scale
Physical Exam
General (Constitutional): Shy but pleasant 5-year-old female, normal general appearance, sits
next mom, very conversational
Skin: Warm and dry, no pallor or cyanosis
Lymph nodes: swollen lymph nodes
Head: NCAT, PERRL, red reflex present bilaterally, light reflex symmetrical, EOMI with no
strabismus
Ears: Left TM is red, bulging, and erythematous, fluid present behind membrane, loss of
landmark and light reflex. Mild pain on palpation. Right TM is pale and grey, landmark present
Eyes: PERRLA, no swelling or lesions over the orbital area, sclera white, conjunctiva moist and
pink
Nose: clear rhinorrhea present, septum midline
Neck: supple, shotty cervical adenopathy
Mouth/Throat: oral mucosa is moist, no lesions, throat without redness or swelling
Lungs: CTAB, no wheezes, rales, or rhonchi
Heart: RRR, no murmurs, rubs, or gallops
GI: Soft, NT/ND, NBS, no masses or organomegaly
MSK: No deformities, normal gait.
Neuro: AOx3, gross motor and sensation intact, normal muscle strength

Assessment
Diagnosis: Acute Otitis Media
Differential Diagnosis:

 Acute Otitis Media

o r/t left ear pain, fever, poor appetite, sleeping difficulties, mild pain
 Otitis Externa
o r/t ear pain, sleeping difficulties, poor appetite
o fluid present behind tympanic membrane, erythema present, no purulent discharge
 Sinusitis
o r/t ear pain and redness,
o denies sinus pressure, <10 days of mucus discharge, denies congestion

Plan

Diagnosis: Otitis Media

Pharmacological treatment/non-pharmacological treatment:
Medication: Amoxicillin 1g orally every 8hrs for 5-7 days, Tylenol for pain/fever, as needed
Patient education:

 Educate about medication adherence

 Educate about signs/symptoms to look out for
 Educate about antibiotic use
 If not any better after the antibiotic treatment, come back for a visit, if worse, go to
ED
 Encourage her to drink plenty of fluids and eat a balanced diet
 More frequent and smaller meals might help with her lack of appetite

Labs and Diagnostic: no labs needed

Referral: none
F/U Plan: ear and temperature monitoring, if worsening please go to the ED.