Dx: Acute Otitis media with efusion

Full Answer Section

Assessment:

• Acute otitis media with effusion

Plan:

• [Treatment plan, including medications, follow-up, etc.]

Please provide the physical examination findings to complete the SOAP note.

Common physical exam findings in acute otitis media with effusion:

• Fever
• Irritability
• Ear tugging
• Bulging, red tympanic membrane
• Decreased mobility of the tympanic membrane

Sample Solution

SOAP Note

Subjective:

• 4-year-old female presented with a 2-day history of right ear pain and discomfort.
• Increased irritability and difficulty sleeping.
• Frequent tugging and grabbing at the right ear.
• Mild fever reported yesterday.

Objective:

• [Physical exam findings: temperature, otoscopic exam, etc.]