Acute Otitis Media Pediatric SOAP Note Example Report

SUBJECTIVE:  The patient is a (XX)-month-old female who presents to the pediatrics clinic today with a six-day history of clear rhinorrhea. For the last two days, she has had a low-grade fever, never going above 101, and she has woken up the last two nights pulling at her ears and screaming in pain. Her appetite was fine until this morning when she did not want to eat breakfast, so her mother decided to bring her in to the clinic. Otherwise, her energy is good and her mother has no other worries or concerns. The patient has no known drug allergies and is on no current medications. Her past medical history is noncontributory.

VITAL SIGNS: Weight 12.6 kg, which is the 66th percentile. It is actually down half a pound since her last visit; however, mother does report that she refused to sit still and the scale was moving and it was hard to get an accurate read. Height 89.2 cm, 91st percentile; OFC 40.2 cm, 75th percentile; temperature 98.2 axillary. Stated pain level now is 0.
GENERAL: The patient is a well-developed, well-nourished female in no apparent distress.
HEENT: Head is normocephalic, atraumatic. Eyes: Positive red reflex bilaterally. Ears: Left TM is red, bulging and erythematous, fluid behind the membrane, loss of landmark and light reflex. Right TM is pale. Nose: There is some clear rhinorrhea. Mouth: Oral mucosa is moist. No lesions.
NECK: Supple, shotty cervical adenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs.
ABDOMEN: Nontender, nondistended, soft. No hepatosplenomegaly.
SKIN: Warm and dry. Cap refill less than 2 seconds. No rashes or lesions.
NEUROLOGIC: Age-appropriate tone and activity.

1.  Acute left otitis media.
2.  Rhinorrhea.

PLAN:  We will start her on cefdinir for the otitis. If symptoms do not improve or worsen in 48 hours, return to clinic. Discussed, with the rhinorrhea, it could be just simple rhinorrhea or mild allergic rhinitis. Either way, we are going to treat it the same with Zyrtec 3 mL at night. Also, recommended a cold air humidifier. If symptoms worsen or do not improve, return to clinic, otherwise follow up p.r.n. We will also do her 12-month shots as she has not had these done. Clinically, she is well and stable and afebrile, so there are no contraindications. All questions were answered. Mother verbalizes understanding and agreement of today’s discussion and advice.

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