SOAP # 1

Date: 09/13/2019 Patient Ethnicity: Hispanic

Initials of Patient: G.A Clinical Setting: ER

Patient Age: 28 years Initials of Provider: AK

Patient Status: ____New ____Established

SUBJECTIVE
Chief Complaint: PT stated “My right ear hurts a lot and its also causing pain in my head right
above my right ear”
History of Present Illness (HPI):
A 28-year old Latin female presented in ER with a severe right earache. PT states her pain
started yesterday, but it was mild, today she woke up with severe pain that is becoming
unbearable. PT states her pains is 8/10 and says pain extend to her right temporal area. She
denies she went to the beach or a swimming pool. She denies sinus pain, nasal pain, fever,
cough, rhinorrhea, or any other medical problems. PMH unremarkable though she is 4 months
pregnant. Her aunt tried to put some oil in her right ear, but it didn’t go in at all.
Review of system specific to HPI:
PT is holding her right ear gingerly and is in apparent pain. Vitals are stable, and she is afebrile.
The pain is extending all the way to the right temporal area. The external ear is unremarkable
without any discharge or erythema. No nasal discharge, pain, or rash. Eyes clear no problem with
vision, no irritation or inflammation. No shortness of breath, cough, wheezes or rales. No chest
pains. No muscle aches, joint pain or rash.
Past History:
No childhood or adult acute or chronic medical or psychiatric illnesses or conditions. No
hospitalization.
Surgery: None
Medications: No prescribed medications or herbs as she is very cautious of taking any
medications due to her pregnancy.
Allergies: No known allergies
Immunization: Immunization up-to-date.
OBJECTIVE DATA
Vital Signs:
BP: 130/75., HR: 90, RR: 18, T: 98.7°F (37.0°C), O2 sat-100%
Height: 5’5 BMI: 25 (Normal)
A 28-year old Hispanic female, that appears her stated age in general good health, well-
nourished, well-groomed, and dressed in clean and appropriate clothes. Appropriate weight and
height for the age. She is holding her right ear gingerly and is in apparent severe pain. PT is
AA&O X 3 and answered all questions appropriately.
Physical examination:
Head/Face: Normocephalic and atraumatic head, face symmetrical without any abnormality.
Eyes: PERLA, no discharge. No glasses or contact lenses.
Ear: Ears symmetrical. On physical exam the ear is painful to touch especially in the tragus,
though no pus or rash is noted on the external surface and ear canal. Otospcopic exam reveals
moderately hyperemic right ear canal extending to middle ear with substantial narrowing of ear
canal. Left ear unremarkable.
Nose: Patent without any discharge. Nasal mucosa pink.
Mouth/Throat/ Neck: Tonsils appear flaming red and have white patches and some exudate.
The roof of the mouth has tiny red spots all over it. Tender cervical lymph nodes upon palpation.
Some halitosis.
Respiratory: Bilateral lung sounds, clear on auscultation. No wheezing or difficulty breathing.
No retractions. No tachypnea.
Cardiac: Clear heart sounds with regular rate and rhythm. No murmurs.
GI: Abdomen appear normal without any mass or bulges, rigidity or guarding. Abdomen soft
with bowel sounds present in all four quadrants upon auscultation. Tympany upon percussion.
Mildly tender upon palpation. No organomegaly.
Skin/Integument: N/A. No rash visible on visible body parts.
Lab: None
ASSESMENT
Main Diagnosis/Problem: Acute Otitis Externa in right ear (ICD 10 – H60.91)
Additional Health Problem/Dx: None
Differential Diagnoses for top diagnoses:
 Otitis Media: Presents with tympanic membrane changes related to middle ear infection,
such as, edema, erythema and immobile tympanic membrane on pneumatic otoscope. In
Otitis media the movement of tragus doesn’t cause any pain.
 Mastoiditis: The mastoid process is extremely tender and painful, with fever and cervical
lymphadenopathy unlike in otitis externa.
  Herpes zoster oticus (MI): Presents as vesicles on external ear canal and posterior
auricle. Usually accompanied by severe otalgia and facial nerve palsy.
Identify Risk Factors: Living in warm, humid climate, swimming, loss of protective cerumen,
excessive moisture in the ear, and ear trauma.
PLAN
Additional Lab test/Diagnostic Test: None
Pharmacologic Management:
1 – Antibiotic: Ofloxacin 0.3% otic drops BID X 10 days
Rx: Ofloxacin
Dose: 0.3% Otic drops
SIG (write like a prescription)
Ofloxacin 0.3% otic drops BID X 10 days
Dispense: 5 ML
Sig: Put 5 drops in the right ear twice a day for 10 days
2. Adjunctive treatment antipyretic and analgesic: Acetaminophen 500mg
Rx: Acetaminophen Tablets
Dose: 500mg Tab PO, q6h PRN for pain; Disp amount: 30
SIG (write like a prescription)
Rx: Acetaminophen 500mg Tab
Dispense: 30
Sig: Take 1 tablet every 6 hours as needed for pain
Non-Pharmacologic Management:
Rest and drink plenty of fluids, preferably water. Ice or heat for pain and inflammation relief.
Complementary Therapies: None
Health Education:
 Do not submerge your ear in water. Keep it dry; take care while showering to not let
water inside the ear.
 You can use ear plugs while showering to protect the ear and use the lowest setting on the
hair dryer to dry the ear.
 Abstain from water sports for 7 to 10 days during treatment.
  The mediation is to be used for 10 days, even if earache gets better continue using it.
 You can use ice pack to reduce pain and inflammation.
 Acetaminophen is for pain you don’t need it if you don’t have pain.
 Return in 48 hours to the ER for removal of the ear wick.
 Return to ER if pain becomes more severe, if discharge becomes purulent, or you develop
very high fever.
Referrals: Primary care physician
Follow-up Appointment: Return to clinic if no improvements happen in 48 hours.

For the Encounter Final Level of Decision Making: (give rationale for level which is based
on Hx, physical, Decision making); Choose one

Billing Code: 4130F & 99281

Straightforward: Patient has presented with a single uncomplicated acute medical condition,
i.e. Acute Otitis Externa (ICD 10 - H60.91). The patient has a good prognosis as long as she
adheres to treatment.

Billing Level: Give the reason for the Billing by E and Coding as per Number of Systems
Reviewed and Level of Physical Exam.

Patient Status: New

Level of history: Problem-focused

Level of physical (exam): Problem-focused

Level of Medical decision making: Straightforward

ANALYSIS

Write 1-2 paragraph summary listing the subjective and objective data that supports your
main diagnosis.

A 28-year old Hispanic female presented with acute right earache without any other
symptoms. She is healthy, without any chronic disease and is four-month pregnant without any
complications. Her vitals are stable, and she is afebrile. She states touching the ear causes severe
pain. On inspection, both ears appear symmetrical without any discharge, rash, or peeling. The
otoscopic exam of left ear shows intact tympanic membranes without any effusion, bulging or
erythema. The cone of light and bony landmarks clearly visible. Ear canals clear, no swelling or
discharge. No pain on touch. The right ear opening is mildly hyperemic, and canals are
moderately erythematous. The right ear canal is narrowed and had difficulty inserting and
viewing the tympanic membrane as it causes severe pain and full exam of the tympanic
membrane was not possible. Any touch causes pain in the right ear, especially around tragus.
There is no cervical lymphadenopathy, and rest of HEENT is clear. These objective findings,
coupled with subjective results (rapid onset, pain on touch, and movement, especially of tragus)
strongly suggest Acute Otitis Externa. The H&P strongly correlates with the diagnosis and no
other lab test is needed especially since there is no discharge, no immunocompromise state or
any structural abnormalities (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

The differential diagnoses were ruled out based on H&P, signs and symptoms, normal
neurologic exam, and normal jaw movement and lack of jaw pain (TMJ dysfunction). Otitis
Media was ruled out due to positive pain on tragus movement. Dental issues were ruled out
based on negative pain complains and examination of mouth, revealing no abscess and healthy
teeth. No rash, crust, eczema or any other skin lesions/conditions rules out insect bites, impetigo
and herpes among others. Absence of pain in mastoid area, absence of fever and cervical
adenopathy rules out mastoiditis (Dunphy, Winland-Brown, Porter, & Thomas, 2015).

Write 1-2 paragraph summary discussing the plan for the main diagnosis.

Acute Otitis Externa is mostly a bacterial infection with Staphylococcus aureus (localized
infection) and Pseudomonas aeruginosa (diffuse infection and invasive otitis externa) being the
two most common causative organisms. Ofloxacin was chosen, and dosage, route, frequency,
and duration of treatment were prescribed as per guidelines. The topical antibiotics provide better
therapeutic level than the oral antibiotics and have less systematic effects. Since the ear canal
was edematous and very narrow, an ear wick was placed in the ear to facilitate the delivery of
otic drops. Ear wick made of cellulose (instead of cotton) are preferred as they expand when wet
and provide reliable delivery of topical medication. Acetaminophen prn was prescribed as
evidence shows it is sufficient for the treatment of otalgia (Rosenfeld, et al., 2014).

No data exists pertaining to efficacy of alternative and complementary treatment; thus,

none is advised. Heat or ice can be applied to lower inflammation and provide pain relief.
Importance of keeping the ear dry should be reinforced by suggesting earplugs during shower
(Rosenfeld, et al., 2014). Educate the patient about cleaning ear by reminding her of the old
saying, "Don't put anything smaller than your elbow in your ear" to clean the ear is true. The ear
is self-cleaning; fingers, towels, cotton-tipped applicators, and other devices should not be used
to clean the inside of the ears.
 References:

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care:
the art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F. A. Davis
Company.
Rosenfeld, R. M., Schwartz, S. R., Cannon, C. R., Roland, P. S., Simon, G. R., Kumar, K. A., …
Robertson, P. J. (2014). Clinical Practice Guideline. Otolaryngology–Head and Neck
Surgery, 150(1_suppl). doi: 10.1177/0194599813517083