Episodic/Focused SOAP Note for Earache Patient Information: Case #3. Patient Initials: J.D. Age: 11 Gender: Male Subjective Chief Complaint (CC) : Earache History of Present Illness (HPI): J.D. is an 11-year-old male who presented to the clinic with a complaint of a mild earache that started two days ago. J.D. reported that the pain is worse at night when he is falling asleep and that it is more difficult for him to hear. J.D. reports frequent swimming over the summer and reports slight fever. J.D. denies any ear discharge, sinus, throat or head pain. J.D.’s grandmother has not given him any medications up to this point. J.D. reports his pain at time of assessment is 4/10. Medications: No Medications Allergies: NKDA Past Medical History (PMH): Hx of tonsillitis. Past Surgical History (PSH): Tonsillectomy. Immunization History: Up to date on immunizations. Significant Family History: Significant substance abuse with both parents. Social History: Attends school regularly, plays sports. Review of systems: General: Reports feeling warm to touch.
HEENT: Slight hearing loss, mild ear pain. Reports ringing in his ears. No history of head trauma, upper respiratory tract infection. No complaints in the mouth or sinuses, no ear discharge. No sore throat or difficulty swallowing. Pulmonary: No difficulty breathing or dyspnea. Allergic/Immunologic: Seasonal allergic rhinitis. Objective Physical Exam: Vita/l signs: B/P - 110/65, P - 90, T – 99.8, RR - 20, Wt - 84 lbs, Ht - 4’10”, BMI -17.6. General: Alert and oriented x4, no distress noted, playful.
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- Summer '15
- Otitis Externa, Inflammations