ENT SOAP NOTES

SOAP NOTES OF ENT

Patient Demographic Data

Initial: U.B Age: 22 years Sex: Female Ethnicity: Gilgit MR# 404-38-42

Subjective
Chief Complaint: Itching in the left ear associated with pain for 4 days.

History of presenting complaint: A 22-year-old female patient presented with the chief
complaint of itching in the left ear, associated with pain of 8/10 for 4 days. She has a
history of otitis externa from 3 months back for which she was taking medications. Pain
was associated with itching relieved after some time and aggravated with the use of cotton
buds. She is not taking any pain medications for this, the pain is persistent.

Allergies: No Allergies

Current medications:
Ear drops Cepotic 3drops QID

Past Medical History: None

Immunisations: All immunisations were complete

Social History:
No history of smoking or other addiction. She lives with her family and has a good
relationship with her family. Working as a home health nurse at AKUH, Karachi.

Family History: No family history.

GM GF

50 45
5y

15 22 10

patient
Key:
 Deceased male: Grandfather died. Cause of death unknown
Deceased female: Grandmother died. Cause of death unknown
Living Male:
Living Female:
Review of Systems [ROS]:
General: The patient denies fever, fatigue, insomnia, weakness, bleeding disorders,
weight loss, and has no history of blood transfusion.

HEENT: Denies headache, denies any injuries. Denies visual changes or drainage. Report
earache. Denies nosebleeds, and nasal congestion with nasal discharge in the throat.
Denies any teeth-related problems, and hoarseness/voice changes.

Respiratory System: Denies SOB, and denies coughing. The patient denies any problem
in the respiratory system.

Cardiovascular: Denise any chest pain or abnormalities. Denies orthopnea or

palpitations. Denies edema or claudication.

Gastrointestinal: Denies pain/cramps, denies diarrhoea, Nausea/Vomiting.

Neurological: Denies anxiousness or memory loss. Denies numbness or tingling.

Musculoskeletal: Denies limitation in ROM. Denies inflammation or tenderness.

Haematology: Denies any bruises, and bleeding.

Psychological: Denies sleeping disturbance. Denies mood disorders or suicidal thoughts.

Objective

General:
Temp: 37C HR: 80/min, RR: 20/min, BP: 127/71mmhg, SO2: 96%, WT: 44kg HT:
155cm

HEENT: No head injuries or trauma. Swelling and redness in the left ear. The tympanic
membrane was translucent with clearly visible landmarks.

SKIN: Warm to touch. No rashes, no petechia or bruises.

CV: Normal findings

RESP: Normal lung sounds.

GI: No tenderness observed.

MUS: muscle strength 5/5. Full ROM.

Differential Diagnosis

1. Otitis Media: The patient's history of otitis externa three months prior suggests a
susceptibility to ear infections. Otitis media, an infection of the middle ear, could
be a potential diagnosis, especially if the current symptoms of pain and itching
persist despite treatment for otitis externa. Additionally, the aggravation of
symptoms with the use of cotton buds may further indicate a middle ear pathology
rather than an external ear issue.

2. Fungal Otitis Externa (Otomycosis): Given the history of otitis externa and the
persistence of symptoms, fungal otitis externa, also known as otomycosis, should
be considered. Otomycosis is a fungal infection of the external ear canal commonly
associated with itching, pain, and discomfort. Additionally, the failure of symptoms
to resolve with previous treatment for otitis externa raises suspicion for a fungal
etiology.

Treatment Plan
 Continue old treatment of Otitis Externa
 Also add Painkillers for pain.
 Take care while having a bath by keeping oil dept cotton in the ear.
 Added Acetic acid 1% 3 drops OD in the infected ear.