Pediatric Soap Note: Otitis Media

Pediatric Soap Note: Otitis Media

Name: O. M.

Date: 02/08/2018

Time: 1030

Age: 4 years

Sex: F

SUBJECTIVE CC: “The child has a fever, running nose, earache, and cough.”

HPI: The child, a four-year female patient, was brought by her grandmother to the facility with complaints of fever, runny nose, decreased appetite, earache, and persistent cough. The symptoms were first detected 3 days ago. The child has been treated with saline nasal spray and Tylenol, but her condition has not improved.

Medications: Tylenol 7ml x3 daily Saline nasal spray

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PMH Allergies: NKDA Chronic Illnesses: none Medication Intolerance: None Hospitalizations/Surgeries: none Vaccinations: up to date Family History Father: alive and healthy Mother: alive and healthy Maternal grandmother – alive and healthy Social History The patient lives with her parents and her two brothers, 8 and one year old. She is exposed to secondary cigarette smoke since both parents are smokers and do it at home. She attends preschool five days every week.

ROS

General The patient has a low-grade fever but does not show signs of weight loss. The child has not shown any changes in appetite Skin Grandmother states that the child does not have skin related problems Eyes Grandmother notes that the child does not have eye

Cardiovascular Grandmother notes that the child does not have cardiovascular problems Respiratory the child was reported to have a persistent cough and a runny nose Gastrointestinal Grandmother noted that the child had not experienced

PEDIATRIC SOAP NOTE: OTITIS MEDIA conditions such as tearing, redness, inflammation, and infections Head: grandmother noted that the child has been complaining of a headache Ears Grandmother noted that the child has been compliaining about pain in the ears. She also noted that abnormal fluid discharge had been observed in the right ear.

Neckthe patient has also been complaining of neck pain Nose/Mouth/Throat The child has a runny nose Throat is non-erythematous She does not have mouth sores Heme/Lymph/Endo grandmother did not report endocrine- related issues

2 gastrointestinal problems such as diarrhea, vomiting, and diarrhea.

Genitourinary/Gynecological The child does not have any detectable genitourinary problems Musculoskeletal Grandmother reports that the child does not have musculoskeletal deformities.

Neurological No neurological problems were reported for this patient Grandmother noted that the child could make sensible sentences to communicate

OBJECTIVE Weight: 36 lbs Temp 38.5 BP: 89/50 Height: 40’’ Resp 25 Osat 98.

General Appearance The patient is active and does not present with signs of distress Skin The patient’s skin is warm to touch with no bruises or infection signs HEENT Head: normalcephalic Eyes: The pupils do not show signs of infection, they are round and reflective to light, the sclera is white and conjunctiva pink Ears: the left ear tympanic membrane is intact and has remarkable mobility. The right ear tympanic membrane is Erythematous. It also appears to be bulging out and has poor mobility and decreased light reflex.

Nose: the child has a clear nasal discharge Neck: The tonsils are not inflammed, the neck is not supple Mouth/Throat: the throat is non-erythematous, and no sores were detected in the mouth.

Cardiovascular S1-S2 present and normal, no gallops and murmurs detected. Pulse+3. No edematous signs Respiratory The physical examination of the lungs is normal. The lungs are clear to auscultation Gastrointestinal The child does not have observable signs of organomegaly, and abdominal distension. Bowel sounds are normal in all quadrants. The Abdomen is soft and non-tender.

Genitourinary Physical examination of the genitals not performed

PEDIATRIC SOAP NOTE: OTITIS MEDIA

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Musculoskeletal The extremities of the child demonstrate a full range of motion.

Neurological The child seems alert and active. The child was also talkative during the visit.

Lymph: small cervical lymph nodes are palpable Lab Tests Otoscope- redness, and swelling detected on the right ear.

Special Tests None Diagnosis Primary Diagnosis Otitis media- a diagnosis of otitis media was made since the child was complaining about pain in the right ear, abnormal discharge was also noted in the right ear (Epocrates, Inc., 2018). The other symptoms that contributed to this diagnosis are fever and decreased appetite. The patient has also been experiencing a headache and neck pain.

Otoscope revealed redness and inflammation in the right ear (Qureishi et al. 2004).

Differential Diagnoses Myringitis- The symptoms of myringitis include ear pain that lasts for over two days, hearing loss, fever, tearing, irritability and fluid drainage from the ears (Epocrates, Inc., 2018).

Mastoiditis- The symptoms of mastoiditis resemble those of an ear infection. They include an earache, redness, and swelling of the affected ear, fever, and hearing loss. The patient may also have drainage in the affected ear. This condition was ruled out because the patient did not have erythema, edema, and tenderness over the mastoid process as indicated by Epocrates, Inc (2018).

Cholesteatoma- This condition is characterized by non-cancerous skin growth in the middle ear. Choleastoma is a congenital disability but can occur in case the child has a history of ear infections. The symptoms of this condition include abnormal drainage from the ear (John & Michael, 2016).

Plan/Therapeutics o Plan:

Further testing Tympanometry and Conventional otoscopy  Medication Amoxicillin: 80-90 mg/kg/day (8 mL) every 12 hours for ten days for possible bacterial infections.

Acetaminophen: 10-15 mg/kg every 4-6 hours for pain and fever control (Epocrates, 2018) 

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Non-medication treatments -Sufficient sleep -Avoid exposure to secondary smoke -Distraction -myringotomy -local heat (Hollier, 2016)

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Education Grandmother was advised to closely watch over the child and ensure she is not exposed to secondary smoke. She was also advised to clean the ears with a clean cloth and warm water.

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Return to office Follow-up was scheduled for 72 hours if the symptoms will not improve after taking medications.

Self-Assessment & Clinical Guidelines Encounter with the grandmother and the child was pleasant since they were willing to disclose information that facilitated the diagnosis and development of a treatment plan. The grandmother was also eager to learn the way by which future cases can be prevented.

There was no need for complex tests since otoscopy which is the main diagnostic test for otitis media had already been performed.

The preceptor clarified that the child was prescribed with amoxicillin due to the high likelihood that she had an infection caused by bacteria (Hollier, 2016). Otitis media is mostly caused by Moraxela catarrhalis, Streptococcus pneumoniae, and non-typeable hemophilus. The bacterial infection is cleared by administration of a single dose of amoxicillin twice daily for ten days (Qureishi et al. 2004). This medication is recommended for younger children since it does not lead to unwarranted side effects.

The child was prescribed with acetaminophen to relieve the earache.

Grandmother was advised to ensure the child is provided with nutritious foods including fruit and vegetables to boost her immunity.

In the future, I would request to talk with the parents to devise a plan for creating a safe home environment for the children

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References Epocrates, Inc. (2018). Acute Otitis Media. Retrieved from https://online.epocrates.com/diseases/39/Acute-otitis-media Hollier, A. (2016). Clinical guidelines in primary. Scott, LA: Advanced Practice Education Associates.

John, L. D., & Michael, B. G. (2016). The chronic ear. New York, NY: Thieme Qureishi, A., Lee, Y., Belfield, K., Birchall, J. P., & Daniel, M. (2014). Update on otitis media – prevention and treatment. Infect Drug Resistance, 7, 15–24. doi: 10.2147/IDR.S39637