Dx: Acute Otitis media with efusion
Using the following case create a soap note base on the template uploaded:
Subjective:
Patient is a 4 years old female who was brought for consultation by her mother. She states patient has been complaining of right eaar pain and discomfort since 2 days ago, she has been more irritable than usual and has had difficulty sleeping. She has also noticed that Emily has been tugging and grabbin at her right ear frequently. Mother also reports an episode of mild fever yesterday.
Dx: Acute Otitis media with efusion
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.]
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