NURS 6541N WK7Assgn2 PT1 Walden University Primary Care of Adolescents & Children

1 NURS 6541N WK7Assgn2 PT1

Week 7 SOAP NOTE Walden University Primary Care of Adolescents & Children

NURS-6541N-14

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SUBJECTIVE DATA

Chief Complaint (CC): “My left ear hurts.”

History of Present Illness (HPI): A 5-year-old Caucasian female with mother. She states that B.S. started complaining of left ear pain last night and keeps tugging on her ear. She states that she has not complained until late last night when she started to go to sleep. B. S. states that her “ear just hurts really bad”. Mother reports that after her bath last night she attempted to clean B.S. ears out and that seemed to aggravate the pain.Mother reports that B.S. has had some clear nasal drainage with nasal stuffiness x 3 days with no fever. Mother states that she gave B.S. some Motrin 5ml and she soon fell asleep.Mother reports that when B.S. woke up this morning she had a temporal temperature of 101.0F and B.S. was complaining of more pain in that ear. Using the faces pain scale B.S.indicates that her ear pain made her feel like the third face on the pain scale.

Medications: Motrin 5ml PO once last night.

Allergies: NKA

Past Medical History (PMH): Allergic Rhinitis. Acute Otitis Media. Up to date with well visit health checks.

Past Surgical History (PSH): No surgeries reported.

Personal/Social History: B.S. is in the 1

st grade, in public school. Mother reports she has no problems at school, and she has made friends.Immunizations: Georgia Registry of Immunizations (GRITS) verified and B.S. is up to date with scheduled vaccines. She received influenza vaccine last on 10/2/17.Family History: Mother-alive, healthy. Father-alive, HTN controlled with medication.One brother 8 years old, healthy.

Review of Systems: - Per mother and B.S.

General: B.S. states that her ear has been hurting all night and she did not sleep well. Mother states that she woke up this morning crying with fever of 101.0F and asked to go to the doctor. Mother states she has been whining and wants to be held, with no interest in playing.Skin: Reports some mosquito bites on bilateral arms that itch. Denies any injuries or open sores.

HEENT: Denies headache. Denies vision problems. Denies putting anything into

the ears. Left ear pain, denies drainage. Reports some nasal congestion at times with clear drainage, reports no pain. B.S. denies any throat pain.

Neck: Denies stiffness or difficulty swallowing.

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Respiratory: Denies any SOB.

Cardiovascular: Mother denies any cardiac problems.

Gastrointestinal: B.S. reports no changes in bowel habits, last BM yesterday at

school. Denies diarrhea. Appetite is usually good but did not want to eat this morning due to pain in the ear.

Peripheral vascular: Mother denies swelling in the extremities.

Urinary: B.S. denies any changes in voiding pattern, reports voiding several

times a day without pain.

OBJECTIVE DATA: BP-Sitting-82/42, Radial Pulse Rate palpated-90, Respirations-26, Temperature-101.8F Oral, O2 Saturation-100% on RA.Ht-35”; Wt-19.5kg; BMI-24.67; 97% Percentile for Ht and Wt. Growth curve appropriate.General: B.S., alert and oriented x4, aware she is at doctor’s office, sitting in lap with mother. Well-groomed and dressed appropriately. Able to voice left ear pain and cooperates with exam. She is able to walk to exam table and normal gait observed. Affect appropriate for age, and able to voice which ear is hurting.SKIN: Warm to touch, no diaphoresis. No rash, open lesions noted, small erythema bumps on bilateral upper extremities noted, consistent with mosquito bites. Skin turgor appropriate. Skin color appropriate for race.HEENT: Head is normo-cephalic. Hair is evenly distributed. PERRLA. Red reflex present bilaterally. Sclera white and clear. Conjunctiva clear. No drainage noted from ears. Otoscope exam of right ear tympanic membrane is clear, no edema or redness, neutral position, identifying landmarks visible. Otoscope exam of left tympanic membrane bulging with yellow bubbly fluid noted, decreased transparency, specific landmarks of middle ear unidentified. Nasal canals patent, no deviation in septum, clear drainage noted, mild edema, mucosa pink and moist. Maxillary sinus tenderness with percussion. Trachea midline. Throat without edema. Tonsils are without erythema, inflammation, exudate or drainage.

Neck: No lymphadenopathy palpated in neck or clavicular. ROM appropriate.

Chest/Lungs: Symmetrical chest expansion. Bilaterally clear lung sounds in all lobes.No accessory muscle use with breathing noted. No wheezing, rales, or rhonchi noted on inspiration or expiration.Heart/Peripheral Vascular: S1 & S2 heart sounds auscultated. No murmurs or gallops noted. Rate and rhythm appropriate for age. Capillary refill <3>

Abdomen: Flat and symmetrical. Bowel sounds active in all 4 quadrants. Soft to

palpitation, no distension noted. No organomegaly palpated. No rebound tenderness.

Genital: Deferred

4 Musculoskeletal: ROM appropriate in all joints noted. Spine is straight, intact, and midline of back. Bilateral strength is equal in all extremities. Gait steady.Neurological: A&O x4. B.S. verbalizes she is at the doctor’s office, mothers name, and reason for visit to doctor. Cranial nerves 2-12 intact.

ASSESSMENT:

Priority Diagnosis- Acute Otitis Media (AOM): This diagnosis is centered on the examination findings of B.S., noting of a bulging tympanic membrane, the decreased transparency, yellow fluid collecting behind the eardrum, and difficulty with identifying landmarks resulting from edema. These characteristics are findings that are diagnostic of AOM based on the otoscope visual exam (Harmes, Blackwood, Burrows, Cooke, Harrison, & Passamani, 2013). B.S. also experiences tenderness to external ear canal when touched, ear pain with a sudden onset last night that has also interfered with her daily activities and no interest in playing. Burns, Dunn, Brady, Starr, & Blosser (2013) affirm that these are characteristic symptoms of AOM, as well as, fever, a decrease in appetite and may also be accompanied by nausea or vomiting.Differential Diagnosis- 1) Otitis Media with Effusion (OME): OME is parallel with AOM but there is no acute infection (Burns et al., 2013). With OME the identification of landmarks in the ear are still visible, they will be afebrile, and ear pain is not as acute as it is with AOM. Children with OME are usually able to continue daily activities without the interruption from pain. Some of the reported symptoms with OME are a popping sound in the ear, fullness feeling in the ear, or muffled hearing (Zakrzewski & Lee, 2013). B.S. complained of severe ear pain and voiced no problems of hearing in that ear, and she was able to identify the ear of complaint when she was questioned during the examination, which verified that there were no issues of hearing deficits.B.S. exhibited symptoms that were different from OME symptoms and ruled out the diagnosis.2) Acute Otitis Externa (AOE): AOE usually presents after having the head exposed to water, afebrile, and does not present with infection. AOE is an inflammation in the ear canal, with possible erythema and edema to the ear, and usually presents in bilateral ears of children (McWilliams, Smith, & Goldman, 2012). B.S. did not present with edema or erythema to external canal during examination, and did not report having her head exposed to water for a long period of time. With these reports and observed symptoms this diagnosis was ruled out.3) Acute Bacterial Sinusitis: Usually the diagnosis sinusitis result from viral upper respiratory infections. There is usually fever accompanied with acute bacterial sinusitis after at least 10 days of a continued upper respiratory illness (Ward, et al., 2013). Some symptoms could be headaches, tenderness in maxillary and frontal sinus cavities because of inflammation, nasal congestion from nasal cavities with edematous (Ward, et al., 2013). B.S. has had purulent nasal drainage for 3 days which could be a sign of acute bacterial sinusitis however, she has not had the cough and upper respiratory symptoms to accompany them (Ward, et al., 2013). Without the