NSG 6435 Week 2 Soap Note Meissner D

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 1 of 4 Student Name: Dina Meissner Course: NSG 6435 Patient Name: (Initials ONLY) AJ Date: 12/5/23 Time: 1200 Ethnicity: White Age: 5 years old Sex : Female SUBJECTIVE (must complete this section) CC : Right ear pain HPI : Mom of the patient reports that right ear ache has started. The patient had an upper respiratory illness with evident nasal discharge and coughing before the ear ache started. The mother of the patient also states that 48 hours before right ear ache and a 102.1F temperature, T.M. was drowsy and had stopped drinking fluids. The mother of the patient reports that her daughter has had frequent sleep disruptions, tugging at his right ear, and a diminished desire to play with her toys. she gives the pain a 6 out of 10. Medications : N/A Previous Medical History: Developmental History: Developed appropriately Allergies: NKDA Medication Intolerances: None Chronic Illnesses/Major traumas: None Immunizations: Up to date Hospitalizations/Surgeries: None Health Promotion/Health Maintenance: Appropriate for age Nutrition/Diet: Exercise/Regimen: appropriate for age Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: N/A Safety Measures: Screening exams: F AMILY HISTORY (must complete this section) M: Livin g, healt hy HTN MGM : Livin g with brea st canc er MGF F : PGM: PGF Social History: Patient is a healthy five-year-old girl. Mom reports that she goes to kindergarten and gets along well with her classmates and that she is learning appropriately. No developmental or social concerns. REVIEW OF SYSTEMS (must complete this section) General : acknowledges fever and malaise. Reports fussiness and irritability Cardiovascular : denies having palpitations and chest pain. Skin : No rashes lumps or bruises Respiratory: Denies any shortness or breath or difficulty in breathing Eyes : Denies change in vision or drainage from eye Gastrointestinal: denies experiencing

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 2 of 4 hematemesis, diarrhea, constipation, nausea, vomiting, or abdominal discomfort . Ears : Right ear pain and tinnitus. Pt tugging at ear Genitourinary/Gynecological: Mom reports decreased appetite. No vomiting or diarrhea Nose/Mouth/Throat. denies congestion, odynophagia, sinus discomfort, running nose, and epistaxis. Recognizes sore throat Musculoskeletal: denies any swelling or joint pain Breast: denies having lumps, discharges, or breast pain. Neurological : denies experiencing seizures, syncope, disorientation, headaches, neck discomfort, or weakness. Heme/Lymph/Endo: denies polyphagia, polyuria, polydipsia, and weight loss denies having anemia, petechiae, purpura, and heavy bleeding. Psychiatric : Denies any confusion OBJECTIVE (Document PERTINENT systems only, Minimum 3) Weight : 42 lb Height : 42 in BMI : 17 BP: 98/50 Temp : 100.0 Pulse: 109 Resp : 21 SPO2 %: 100% General Appearance: Pt appears lethargic and fussy Skin : No rashes, lumps or bruises noted on the body HEENT : Red, protruding (full) ear drum. Purulent, clear, yellowish, or greenish discharge that may also contain some blood. ear drum that is immobile Cardiovascular: Regular rate and rhythm Respiratory : No adventincious lung sounds. No dyspnea noted on exam . Gastrointestinal: No abdominal tenderness Breast : Genitourinary : Musculoskeletal: Neurological: Psychiatric : Diagnostic N/A Special Tests: N/A DIAGNOSIS (Minimum required differential and presumptive dx's, can do more) Differential Diagnoses  Diagnosis, (ICD 10 code and reference): Acute Otitis Media H65.00 Acute otitis media (AOM) is a suppurative, acute infectious condition characterized by inflammation of the mucosa lining the middle ear cavity and the presence of infected middle ear fluid. The illness is usually caused by abnormalities in the Eustachian tube's function, which lead to the retention and purging of secretions. A perforated tympanic membrane may also be linked to purulent otorrhea in cases of AOM. Most of the time, AOM reacts quickly to antibiotic therapy (Suzuki et al., 2020).  Diagnosis, (ICD 10 code and reference): Perichondritis H61.019 An infection of the skin and tissue around the outer ear cartilage is called perichondritis. The most common causes of perichondritis are ear injuries from sports injuries, piercings, and ear surgery (Rivera- Morales et al., n.d.).  Diagnosis, (ICD 10 code and reference): Otitis externa H60.9 The illness known as otitis externa results in inflammation (redness and swelling) of the external ear canal, which is the passageway that connects the Diagnosis  Presumptive diagnosis (ICD 10 code and reference): Acute Otitis Media H65.00

C ONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Note s 11202 3 Page 4 of 4