SOAP Note.edited (1).docx - 1 SOAP Note Focused Ear Exam Patient Information James 11 Male Race unknown S CC mild earache HPI James was brought to the

SOAP Note.edited (1).docx - 1 SOAP Note Focused Ear Exam...

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1 SOAP Note: Focused Ear Exam Patient Information: James, 11, Male, Race unknown S. CC: mild earache HPI : James was brought to the clinic by his grandmother to have his right ear examined. Over the past two days, the patient had suffered a mild earache, which he rated at seven out of ten. The patient claimed that the pain worsened when he fell asleep, and it was more difficult for him to hear. The patient had a prominent tan, which he acquired during the summer by spending a lot of time in the swimming pool. The patient's grandmother did not mention using any ear drops to ease the pain. Current Medications : none mentioned Allergies: no allergies PMHx : the patient’s immunization is up-to-date: Pneumonia (seven months ago); Flu vaccine (four months ago); Tdap (eleven months ago). The patient has no history of chronic illnesses, hospitalization, surgery, or injury. Soc Hx : his hobbies include playing baseball and swimming. He was advised by his grandmother to use the cream after swimming, but he forgot several times. Fam Hx : No relevant family history ROS : GENERAL: no fatigue, chills, or fever; oriented to time, person, and place
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2 HEENT: The patient's last ENT was four months ago, has no eyeglasses/contacts, denies having problems with vision, has mild ear pain, hearing problems, denies having a sore throat SKIN: prominent skin tan CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or
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  • Summer '20
  • Otitis Externa

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