D.M gets up in the morning, bathes, eats breakfast, and walks to school through the crowded streets. He reads, feeds, and plays with his classmates at school. After school, he travels to the field with his pals for daily football matches before returning home to do his homework.
The patient and his mother arrived at the hospital complaining of severe ear ache. He said the pain had worsened since yesterday making it impossible to read or sleep. He admits that he started feeling the pain 4 months ago but says that it is at its worst today. Rates the pain as 8/10. Although the pain fluctuates often, D.M says that the pain is worst in the evening and at night. The patient does not know the origin of the pain, but the mother accuses him of listening to loud music with his headphones. Following an advice by the mother, the patient applies a warm, moist washcloth over the infected ear to ease the pain. At the peak of the ear pain, the patient experiences one or some of the following: nausea, vomiting, imbalance, and irritability.
Medications: Clindamycin- 4 times a day- to relieve pain in the ear.
PMH:
Allergies: Diagnosed with nasal allergies since he was 4 years old. Allergic to dust and pollen.
Chronic Illnesses/Major traumas: No major chronic illness or major trauma reported
Hospitalizations/Surgeries: Immunizations: Fully immunized as other children her age (immunization up to date).
Family History: D.M lives with his mother, father, and 3 year old sister. The mother is 29 while the father is 32 years old. The mother is fully healthy but the father was diagnosed with bronchitis.
Social History: D.M is in grade 5. His mother is a part time cook at a big restaurant in the neighborhood. His father is a manager with in a construction company. His father has been a smoker for more than 6 years.
REVIEW OF SYSTEMS
General: Patient well nourished, no major illness
Cardiovascular:
Skin:
Respiratory:
Head:
Breast:
Eyes:
Gastrointestinal:
Ears:
Musculoskeletal:
Nose/Mouth/Throat:
Neurological:
Genitourinary/Gynecological:
Heme/Lymph/Endo:
DevelopmentalProblems:
Behavioral Status/Psychiatric:
OBJECTIVE
(Attachgrowthchartwith height/weight/headcircumferenceplotted ¬ingpercentiles; attach these forms to the end of your SOAP note)
Weight: 70lbs
Temp: 37
BP: 116/74
Height: 55 inches
Pulse: 84bpm
Respirations:
General Appearance & parent‐child interaction: The patient appeared to be well nourished. He showed no signs of distress. He smiled and answered questions promptly. Occasionally touching his left ear.
Skin:
No rash, bruising or swelling. No cyanosis or jaundice.
Head: normocephalic head, closed fontanels, all structure lines are intact, normal hair distribution.
Eyes: white sclera, pink conjunctivae, pupils are responsive as normal, intact movements of extraocular., positive red reflex bilaterally.
Ears: Externally, the ears appear normal without any lesion, swelling, or redness. However, an otoscopic exam shows that inner ear and tympanic membranes are red. Left tympanic membrane is erythematous and bulging. There is fluid behind the tympanic membrane, loss of landmark and light reflex. Hearing is normal/intact. Right TM is pale.
Nose: lesions or inflammations present, rhinorrhea present, septum is midline, nares patent, no nasal flaring.
Throat/Mouth: patient has 20 teeth, the mouth is pink and moist and has mucous membranes. No oral lesions. Pharynx without erythema or exudates.
Neck: no masses, supple, mobile nontender, right cervical lymp node, 1 cm palpable.
Cardiovascular:
Normal S1/S2. Regular rate and rhythm. No murmurs, rubs, clicks or gallops. Capillary refill
