Running head: EAR INFECTION1Ear Infection Comprehensive SOAP ExemplarWhitney SmithWalden UniversityNURS 6512, Section 38, Advanced Health AssessmentSeptember 27, 2019
EXTERNAL OTITIS2Comprehensive SOAP ExemplarPurpose: To demonstrate what each section of the SOAP note should include. Remember that Nurse Practitioners treat patients in a holistic manner and your SOAP note should reflect that premise.Patient Initials: JMAge:11Gender: MaleSUBJECTIVE DATA: Chief Complaint (CC): Right earacheHistory of Present Illness: 11-year-old Hispanic male patient has developed an aching pain in his right ear that began two days ago. He states “the pain is continuous and achy”. The pain he states “worsens when trying to fall asleep at night, especially laying on the right side”. The patient states his current pain at 7/10. Ibuprofen and Tylenol has helped lower the pain to a 1/10 rating, but never alleviates it altogether. The patient is having difficulty hearing out of the right ear and the persistent pain without relief taking Ibuprofen and Tylenol. The patient’s grandmother states that he has been spending a lot of time in the swimming pool these summer months.Medication: 1) Acetaminophen by mouth 500 mg every 4 hours as needed for pain2) Ibuprofen by mouth 300 mg every 6 hours as needed for painAllergies: No known allergiesPast Medical History: Recurrent otitis media as a child. No hospitalizations other than birth.
EXTERNAL OTITIS3Sexual/Reproductive History:HeterosexualNot sexually activePersonal/Social History:He is an only child. Lives at home with mother and grandmother. His father has not been involved since birth. Smoke detectors and carbon monoxide detectors are present and working in the house. Exposure to secondhand smoke noted, grandmother states her daughtersmokes outside the home on the porch. Patient denies use of tobacco, ETOH, and illicit drug use. Grandmother states her daughter and her once a month have a couple glasses of wine. Always wears seatbelt and rides in the backseat of car. Wears helmet when on bike. Lives in a quiet beach town neighborhood. His family is involved in the community, church, and volunteers at the local aquarium. Immunization History:His immunizations are up to date, tetanus and flu shot Septemeber 2019.Significant Family History:Grandmother is 60 with hypertension and breast cancer following a left mastectomy. Mother is 31 and healthy. Grandfather passed away in 2005 from prostate cancer. Father’s health is not known.Lifestyle:
EXTERNAL OTITIS4He is an active boy involved in swimming and soccer. His mother and grandmother are a great support system encouraging him to stay as active as he can be. They are financially stable but his mother and grandmother both work two jobs without child support. They live in Carolina Beach, NC and often visit the pool and beach. He has never missed an annual
You've reached the end of your free preview.
Want to read all 11 pages?
- Summer '15