SOAP NOTE

Name: R. L

Date: 05/09/2018

Sex: M

Age/DOB/Place of Birth: 2 years 02/28/2015 /Miami, Florida

SUBJECTIVE

Historian: Patient is a 2 years old which is unable to give his medical history and has no developmental delay

Present Concerns/CC: “Member presents to the office with his mother who states “R.L is complaining of fever of 101.0 F during the last 3 days, diminished appetite, runny nose and he grabs his R ear often.”.

Child Profile: A 2 years old member presents to the office with his mother who states “R.L is complaining of fever of 101.0 F during the last 3 days, diminished appetite and he grabs his R ear often.” Her mother is concerned he may having an ear infection because he was playing with the house during the holy week. She states he is a healthy boy delivered at 40 weeks of gestation by C section. The pain was defined by observation from the child pulling of his ear during the visit.

Developmental Growth

As per mom, he recognizes names of familiar people, objects, and body parts, he follows simple instructions, he like to scribbles in a paper sheet and kicks a balls.

During the interview, he walks alone, Climbs onto and down from furniture unassisted, he was able to points to object or picture when it’s named for him, stands on tiptoe and Uses two- to four-word sentences

HPI:

A 2 years old member presents to the office with his mother who states “R.L is complaining of fever of 101F during the last 3 days, diminished appetite and he grabs his R ear often.”

Medications:

None

PMH:

Allergies: None

Medication Intolerances: none

Chronic Illnesses: none

Hospitalizations/Surgeries: None Immunizations: Up to date

Family History:

Maternal Grandmother: Alive – Hypertension, diabetes Mellitus type 2, osteoarthritis

Maternal Grandfather: Alive - Hypertension, gout

Paternal Grandmother: Unknown Medical History

Paternal Grandfather: Lives in another country

Father – healthy

Mother – healthy

Social History:

2 years old male member who lives in a house with his both parents. Both parents are realtors and they denied the use on any recreational drugs at home. No safety Hazards at home. Both parents involve in the client care and support. He attend to a daycare from Monday to Friday. He like music, to kick balls and to scribbles in a paper sheet. Client was dress properly and clean.

ROS

General

fever, diminished appetite,

;

Cardiovascular

Denies chest pain or tightness

Skin

Denies rash, bruising, skin tears, discoloration or lesions

Respiratory

Denies history of pneumonia

Eyes

White sclera, Pupil equal, round, react to light and accommodation

Gastrointestinal

Denies n/v/d, constipation, bowel movements daily, last bowel movement effective today, Eat regular meals and he drinks regular milk. Diminished Appetite

Ears

Pain defined by observation from the child pulling of his ear during the visit.

Genitourinary/Gynecological

Normal urination, Not bladder distension. Tanner 1

Nose/Mouth/Throat

Observed nasal clear drainage, not lymph node distension

Musculoskeletal

Denies history of scoliosis

Breast

Tanner 1, denies breast lumps

Neurological

Denies seizures, c/o generalized pain

Heme/Lymph/Endo

No pending labs

Psychiatric

Denies sleeping difficulties

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart

Weight: 30.4 lbs

Temp: 100.0 F

BP: 95/64 mmHg

Height: 3”

Pulse: 111 x’

RR: 30 x’

SpO2: 96 % at Room air

SPo

General Appearance and parent‐child interaction

Client was dress properly and clean. Good rapport with mother.

Skin

Warm, dry, clean and intact. Mother denies rashes

HEENT

Head: hair evenly distributed. Eyes: pupils equal round reactive to light and accommodation. No conjunctivitis. Ears: Canal patent. R ear redness. Bilateral pearly grey with positive light reflex. Nose: nasal mucosa pink, Observed a clear discharge. No deviation to septum. Neck supple, full range of motion. No cervical lymphadenopathy. Oral mucosa moist and pink. Pharynx erythematous and with no exudates. Teeth are in good condition.

Cardiovascular

S1, S2 regular rate and rhythm.

Respiratory

Chest wall symmetric

Gastrointestinal

Abdomen soft non-tender, BS active in all four quadrants. No hepatosplenomegaly

Breast

Tanner I (male)

Genitourinary

Denies burning with urination

Musculoskeletal

Normal range of motion in all extremities as patient ambulates around the office, and c/o of generalized pain.

Neurological

Speech clear, good tone and coordination. Balance stable, gait steady, walks alone, Climbs onto and down from furniture unassisted

Psychiatric

AAOx3, well-groomed with clean clothing, maintain eye contact and answers questions appropriately to the best of his ability

In-house Lab Tests

none

(HEADSSSVG Assessment)

Patient lives with both parents, no pets at home. Mother states that he is safe at home, no concerns about safety hazards. Denies any guns or weapons in the home. He goes to a daycare from Monday to Friday. On weekends, he plays at home or he going out with his father.

Diagnosis

Differential diagnosis

H73.19 Myringitis: These patients may have no symptoms attributable to the middle ear.

H70.893 Mastoiditis: There is no edema, erythema, and tenderness over the mastoid process.

H71.90 Cholesteatoma: Patients may present with painless otorrhea and hearing loss. Opacification of the tympanic membrane may lead to a misdiagnosis of AOM

.  

· Final diagnosis

· H65.01 Acute serous otitis media, right ear: A physical examination was normal except for findings of a slightly red left tympanic membrane with no middle-ear fluid and a bulging right tympanic membrane with white fluid behind it, obscuring the umbo (Hendley, 2002).

                      Plan

· Medication: 

· Amoxicillin 80mg/kg, PO, Daily, x 7 days. Early diagnosis and treatment of AOM, including the rational use of antibiotics should be improved, by incorporating clinical algorithms in current outpatient guidelines and by supporting the use of otoscopy in primary care practice (Monasta, Ronfani, Marchetti, Montico, Brumatti, Bavcar, Barbiero & Tamburlini, 2012).

· Education:  

· Hand hygiene

· Proper hydration

· Use tissue for mucous and dispose properly

· Instruct mother about Amoxicillin such: Shake the oral suspension (liquid) well just before you measure a dose. Measure the liquid with a special dose-measuring spoon or medicine cup, not with a regular table spoon.

· Take this medication for the full prescribed length of time. His symptoms may improve before the infection is completely cleared.

· Antibiotic medicines can cause diarrhea, which may be a sign of a new infection. If he has diarrhea that is watery or bloody, stop taking amoxicillin and call your doctor. Do not use anti-diarrhea medicine unless your doctor tells you to.

· You may store liquid amoxicillin in a refrigerator but do not allow it to freeze. Throw away any liquid amoxicillin that is not used within 14 days after it was mixed at the pharmacy.

· Avoid taking baths in pools