Heather Cunningham

SOAP Note #1: Primary Care I

Introduction: 2/9/21: S. T. is a 2-year-old Caucasian female brought in today to Collom and
Carney Clinic-Texarkana by her mother.
Chief Complaint: “left ear pain and fever”
HPI: All information provided by S. T.’s mother this visit. She reports S. T. has had a fever for
two weeks that occurs intermittently and reached a high of 101.3 two days ago. The fever is
worse at bedtime and is alleviated with the use of Children’s acetaminophen and ibuprofen,
alternating every 4-6 hours as needed. S. T. began pulling at her left ear 3 days ago and states “it
hurts” when touching it. S. T. seems more bothered by the ear pain at night. It is alleviated with
the use of a warm compress. S. T. has not experienced these symptoms or been diagnosed with
an ear infection before. She reports other symptoms of rhinorrhea and increased fussiness. Her
mother denies cough, sore throat, decreased appetite, diarrhea, or other GI symptoms.
Developmental History: S. T. is meeting all developmental milestones including the following:
plays well with other children, saying 2–4-word sentences, follows two-step instructions, builds
a tower of 4 or more blocks, throws a ball overhanded, climbs onto furniture without help, kicks
a ball, and repeats words heard in a conversation.
Family History:
Mother: no past medical history
Father: no past medical history
Only child, no siblings
Past Medical History: upper respiratory infection (May 2020), Born at full-term via vaginal
delivery, no delivery complications; Surgical History: none; Social History: lives at home with
both parents, no pets or smokers in the home, sits in a rear-facing car seat, eating a well-balanced
diet and 2-3 six-ounce cups of whole milk daily, does not attend daycare; Immunizations: up to
date on all childhood immunizations; Allergies: no known food, drug, or seasonal allergies;
Medications: none
Review of Systems:
General: Reports fever and irritability. Denies decreased appetite or fluid intake. Denies lethargy,
syncope, or change in level of consciousness.
HEENT: Reports otalgia to left ear and rhinorrhea. Denies drainage or redness to ears, sore
throat, or excessive tearing or redness to eyes.
Gastrointestinal: Denies diarrhea, constipation, nausea or vomiting.
Respiratory: Denies cough, chest congestion, or difficulty breathing. Denies apnea or snoring.
Cardiovascular: Denies edema or complaints of chest pain. Denies cyanosis or other skin color
changes.
Physical Exam:
General: Patient is awake and alert. Pleasant affect, smiling and calm. Well-nourished and
dressed appropriate for weather. Skin is warm and dry without lesions or rashes. No signs of
anxiety, respiratory distress, or dehydration.
HEENT: Head is normocephalic. Bilateral eyes symmetrical, conjunctiva pink and sclera white
without erythema or drainage. Nose is midline, nares patent bilaterally. Nasal mucosa pink and
moist with clear drainage. Oral mucosa pink and moist without lesions, tongue is midline,
posterior oropharynx pink and moist without erythema. Bilateral external ears normal without
drainage or erythema. Left ear canal erythematous, tympanic membrane red and bulging,
decreased cone of light. Right ear canal normal without erythema or drainage, tympanic
membrane visible and pearly grey with visible cone of light. Tonsillar lymph nodes palpable.
Gastrointestinal: Abdomen symmetric without visible bulges or masses. Bowel sounds
normoactive x 4 quadrants. Abdomen soft and nontender without distention or masses.
Respiratory: Respirations even and unlabored at rest, respirations regular and 32. All lung fields
CTA without adventitious breath sounds.
Cardiovascular: Heart rate and rhythm regular, S1 and S2 audible without murmurs. Bilateral
radial and dorsalis pedis pulses palpable.
Primary diagnosis: Acute otitis media, left ear
Differential diagnosis:
1.) Serous otitis media
2.) Foreign body in the ear
3.) Impacted cerumen
(Seller & Symons, 2018)
Diagnostics: Diagnosis made by use of otoscope during physical exam; other diagnostic
measures could include tympanometry, acoustic reflectometry, and tympanocentesis
Medications: Amoxicillin Clavulanate (Augmentin) 400mg/5ml: 6 ml BID X 10 days, 0 refills,
pt weight: 11kg, Histex 2.5ml Q6H, quantity 8 oz, refills 1, OTC medications: Culturelle
Probiotic packets, one packet daily x 10 days, Children’s acetaminophen 5 ml (160mg) Q6H
PRN fever; Non-Rx interventions: warm compress, refrain from lying down while drinking
from sippy cup, use of cool-mist humidifier for nasal congestion
Referral: None; will make referral to ENT physician if more than 4 ear infections occur in one
year or more than 3 in a 6-month period
Education: Education provided regarding prevention measures for ear infections including no
cigarette smoking around child, no use of bottle or sippy cups while laying down, and refraining
from using Q-tips. Education also provided on new medications, their intended uses, dosages,
and side effects. Follow-up: Patient to follow up in 7-10 days if symptoms persist or worsen, or
for next well-child visit if treatment plan is effective
 References
Seller, R. H. & Symons, A. B. (2018). Differential diagnosis of common complaints. (7th ed.).

Philadelphia, PA.