Patient! Peter Collins is a 14 Yrs old patient with a diagnosis of Otitis media
Patient! Peter Collins is a 14 Yrs old patient with a diagnosis of Otitis media. Patient came into the clinic with Ear pain, especially when lying down, Tugging or pulling at an ear, Trouble sleeping, Crying more than usual, Fussiness, Trouble hearing or responding to sounds, Loss of balance and Fever of 100 F (38 C). Ear exams, physical assessment and blood work done. Complete medical history and physical examination, inspect the outer ear(s) and eardrum(s) using an otoscope. Antibiotics and Ibuprofen ordered.
Please, write a detailed SOAP Note using the attached template. Also address the below mentioned points.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.
Assignment!
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
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