Patient Scenario for Pediatric SOAP Note
“Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he\’s been spending his summer, James responds that he\’s been spending a lot of time in the pool. Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\’s differential diagnosis and justify why you selected each.”
Pediatric SOAP Note Example
Patient Information
Initials: J.D., Age: 11, Sex: Male, Race: Not specified (additional inquiry needed)
S. (Subjective)
CC (Chief Complaint):
“Mild earache for 2 days”
HPI (History of Present Illness):
J.D. is an 11-year-old male presenting with a mild earache in his right ear that has persisted for the past 2 days. The pain is described as mild during the day but worsens when he’s falling asleep. James also reports difficulty hearing, which may indicate conductive hearing loss. His grandmother, who brought him in, believes he feels warm but did not verify this with a thermometer. The LOCATES assessment is as follows:
- Location: Right ear
- Onset: 2 days ago
- Character: Mild ache, worse at night
- Associated symptoms: Possible fever, decreased hearing
- Timing: Continuous, worse when falling asleep
- Exacerbating/Relieving factors: None reported
- Severity: Mild during day, moderate at night (specific pain scale rating to be obtained)
James reports spending a lot of time in the pool this summer, which may be a contributing factor to his current condition.
Current Medications:
None reported. Verify with guardian if any over-the-counter medications have been given.
Allergies:
None reported. Confirm with patient and guardian.
PMHx (Past Medical History):
No significant past medical history reported. Inquire about previous ear infections, respiratory issues, or chronic conditions.
Immunization status: To be verified with guardian. Ensure all age-appropriate vaccinations are up to date.
Soc Hx (Social History):
- Occupation: Student (grade to be confirmed)
- Hobbies: Swimming (frequent pool use reported)
- Family status: Lives with grandmother (clarify living situation and parental involvement)
- Tobacco & alcohol use: Not applicable due to age, but good to confirm no exposure
- Health promotion: Inquire about seatbelt use, helmet use for biking/skating, screen time habits
- Living environment: To be assessed (urban/rural, exposure to secondhand smoke, etc.)
- Support system: Grandmother present, inquire about other family members or caregivers
Fam Hx (Family History):
No relevant family history reported initially. Further inquiry needed regarding:
- History of ear problems or hearing loss in first-degree relatives
- Chronic illnesses with possible genetic predisposition (e.g., diabetes, hypertension, autoimmune disorders)
- Contagious or chronic illnesses in the household
ROS (Review of Systems):
- General: Possible fever (unverified), no reported weight loss, chills, weakness, or fatigue
- HEENT:
- Eyes: No reported vision changes, redness, or discharge
- Ears: Right ear pain, decreased hearing. No reported tinnitus or vertigo
- Nose: No reported congestion, rhinorrhea, or epistaxis
- Throat: No reported sore throat, difficulty swallowing, or voice changes
- Skin: Prominent tan noted, no reported rashes or lesions
- Cardiovascular: No reported chest pain, palpitations, or edema
- Respiratory: No reported cough, shortness of breath, or wheezing
- Gastrointestinal: No reported nausea, vomiting, diarrhea, or abdominal pain
- Genitourinary: No reported dysuria, frequency, or urgency
- Neurological: No reported headaches, dizziness, or balance issues
- Musculoskeletal: No reported joint pain or muscle weakness
- Hematologic: No reported easy bruising or bleeding
- Lymphatic: No reported swollen glands
- Psychiatric: No reported mood changes or sleep disturbances
- Endocrinologic: No reported polyuria or polydipsia
- Allergies/Immunologic: No reported seasonal allergies or recent illnesses
O. (Objective)
Physical Examination:
- General: Alert, cooperative 11-year-old male with prominent tan. No acute distress observed.
- Vital Signs:
- Temperature: 37.8°C (100.0°F) (mild fever)
- Heart Rate: 88 bpm
- Respiratory Rate: 18 breaths/min
- Blood Pressure: 110/70 mmHg
- SpO2: 99% on room air
- Weight: 40 kg (88 lbs)
- Height: 145 cm (57 inches)
- HEENT:
- Eyes: PERRLA, EOMI, conjunctivae clear, no discharge
- Ears: Right ear examination reveals erythema and bulging of the tympanic membrane with decreased mobility. Left ear appears normal with good light reflex.
- Nose: No nasal discharge or congestion
- Throat: Oropharynx clear, no erythema or exudates, tonsils grade 1
- Neck: Supple, no lymphadenopathy
- Skin: Tanned appearance, warm and dry, no rashes or lesions noted
- Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
- Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
- Abdomen: Soft, non-tender, non-distended, normal bowel sounds
- Musculoskeletal: Full range of motion in all extremities
- Neurological: Alert and oriented, cranial nerves II-XII intact
Diagnostic Results:
- Otoscopic examination of right ear: Erythema and bulging of tympanic membrane, decreased mobility
- Tympanometry: (to be performed) – expected to show decreased mobility of the right tympanic membrane
- Audiometry: (to be performed if available) – expected to show potential conductive hearing loss in the right ear
A. (Assessment)
Differential Diagnoses:
- Acute Otitis Media (primary diagnosis)
- Justification: Presenting symptoms of ear pain, decreased hearing, and fever are classic for AOM. Otoscopic examination revealing a red, bulging tympanic membrane strongly supports this diagnosis.
- Evidence: According to the American Academy of Pediatrics (AAP) guidelines, AOM is diagnosed in children who present with moderate to severe bulging of the tympanic membrane or new onset of otorrhea not due to otitis externa (Lieberthal et al., 2013).
- Otitis Externa
- Justification: Given the history of frequent swimming, otitis externa is a possibility. However, the bulging tympanic membrane is more consistent with otitis media.
- Evidence: The Clinical Practice Guideline for Acute Otitis Externa states that the most common symptoms are otalgia, itching, and fullness, with variable otorrhea (Rosenfeld et al., 2014).
- Eustachian Tube Dysfunction
- Justification: While this could explain the ear discomfort and hearing changes, it typically doesn’t present with fever or a bulging tympanic membrane.
- Evidence: Eustachian tube dysfunction is characterized by ear fullness, popping, pain, and muffled hearing but usually lacks the inflammatory signs seen in this case (Schilder et al., 2015).
- Cerumen Impaction
- Justification: Could cause discomfort and hearing loss but wouldn’t explain the fever or tympanic membrane changes.
- Evidence: The American Academy of Otolaryngology-Head and Neck Surgery Foundation states that cerumen impaction can cause hearing loss, ear pain, and tinnitus but is not associated with fever or tympanic membrane inflammation (Schwartz et al., 2017).
- Referred Pain from Dental Issue
- Justification: While dental issues can cause ear pain, they don’t typically cause changes in the tympanic membrane or hearing loss.
- Evidence: A study in the Journal of Dental Research notes that dental pain can refer to the ear but is not associated with otoscopic changes or conductive hearing loss (Renton et al., 2012).
Primary Diagnosis: Acute Otitis Media
P. (Plan)
While this section is not required for NURS 6512, a brief outline of potential next steps could include:
- Analgesics for pain and fever management
- Consider antibiotic therapy based on severity and duration of symptoms
- Follow-up in 48-72 hours if symptoms persist or worsen
- Patient education on ear care and swimming precautions
References
- Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T. G., Hoberman, A., Jackson, M. A., … & Tunkel, D. E. (2013). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999.
- 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: acute otitis externa. Otolaryngology–Head and Neck Surgery, 150(1 Suppl), S1-S24.
- Schilder, A. G., Bhutta, M. F., Butler, C. C., Holy, C., Levine, L. H., Kvaerner, K. J., … & Takahashi, H. (2015). Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clinical Otolaryngology, 40(5), 407-411.
- Schwartz, S. R., Magit, A. E., Rosenfeld, R. M., Ballachanda, B. B., Hackell, J. M., Krouse, H. J., … & Cunningham Jr, E. R. (2017). Clinical practice guideline (update): earwax (cerumen impaction). Otolaryngology–Head and Neck Surgery, 156(1_suppl), S1-S29.
- Renton, T., Egbuniwe, O., Gaffen, A., & Mian, M. (2012). Orofacial pain in the community: prevalence and associated impact. Community Dentistry and Oral Epidemiology, 40(6), 534-540.
