Based on the following case study and using the sample uploaded, create a SOAP note using references no older than 5 years old.: Patient is a 4 years old male,
Based on the following case study and using the sample uploaded, create a SOAP note using references no older than 5 years old.:
Patient is a 4 years old male, who is brought today for consultation by his mother and grandmother. Parent reports patient has been experiencing redness and swelling of his glans since a few days ago. On the physical examination patient hyperactive, playing, there is swelling and redness of the glans of his penis, no evidence of pus, parent denies fever. We ordered ibuprofen if needed for pain or discomfort, plus oral and topic antibiotics for 7 days.
Patient initials: A.L.
Age: 12 y/o
Race: Hispanic
Gender: Male
Insurance: PPO
Information Source: Given by patient’s mother
Allergies: NKA.
Medication History: Tylenol 500 mg for pain or fever
Family History:
Mother Alive: 36 y/o / Healthy
Father Alive: 45 y/o/ Healthy
1Sister Alive 16 Healthy
Negative Hx for Cancer, Dead for CV event, Allergies: NKA.
Medication History: Tylenol 500 mg for pain or fever
Family History:
Mother Alive: 36 y/o / Healthy
Father Alive: 45 y/o/ Healthy
1Sister Alive 16 Healthy
Negative Hx for Cancer, Dead for CV event.
Past medical History (PMH): Negative for Chronic Disease. Unremarkable. Delivered at 39.2 W2D. Spontaneous vaginal delivery was uneventful. Normal birth weight, Apgar score 8/9. DC two days after delivery
Immunization status: Up to date on all vaccines. : DTAP (5 doses); Hib (4 doses) IPV (4 doses); MMR (2dose); VAR (2 doses); HBV (3 doses); PCV (4 doses); RV (3 doses); HAV (2 doses); Influenza vaccine received on 12/19/2019
Developmental stage: Normal development according to his age.
Hospitalization: No previous hospitalization.
History of mental illness/personality disorders: None.
Physical trauma/falls: No reported during the last twelve months.
Surgeries: No previous history
Exercise: No engage in any regular exercise’s regimen/ only school sport activities (Hold now due to COVID 19 pandemic)
Diet: Regular and well balanced.
Social History: Patient lives with his married parents in an apartment. Normal familiar dynamic, he has a healthy sister 16 y/o. He is a middle school student with good/normal development and social interaction Denied smoke, alcohol intake and use or recreational drugs. , No second-hand smoking exposure. Denies being sexually active
Last annual physical exam: 12/19/2019 (Normal)
SUBJECTIVE
Chief complaint: “My child has Left ear pain for 2 days"
History of present illness (HPI): A.L is an 12-year-old Hispanic male healthy patient, who came to the office today, complaining of left ear pain (rated 5-10) for two days as per her mother referred with the previous history of the patient started with an Upper Respiratory infection (URI) symptoms such as nasal secretion and nasal congestion seven days ago after the nasal discharge was yellow, little appetite and nausea in the child began to complain of earache that has been alleviated with drops of warm oil and today starts with a high fever that was treated with Tylenol, her mother notices the sleepy and malaise child, denies vomiting, dizziness or other symptoms
REVIEW OF SYSTEMS:
Systemic: Patient complaint fever about 102.2. He denied change in appetite; tired, weakness or sleep disorder.
HEENT. Head: Patient complaint left ear pain 5/ 10, No history of trauma, no complaining of headache. No sinus pain or any other facial pain is stated.
Neck: Denies pain or stiffness. No swollen glands in the neck. Eyes: Denies blurring vision, double vision, redness or eye discharge. Oto-laryngeal : Complains left ear pain , yellow nose discharge and congestion , denies nasal bleeding. Denies bleeding gums. No hoarseness. last dental exam was 6 months ago, no cavities
Cardiovascular: Denies chest pain, palpitation or edema on the lower extremities.
Respiratory: Denies shortness of breath, cough or wheeze. No complaints of chest congestion.
Gastrointestinal: Denied appetite problems. Denied abdominal pain, no food intolerances, no nausea or vomiting, no constipation. Last bowel movement: 07/20/2020
Genitourinary: Denies changes in urinary habits, normal urinary frequency. Denies history of kidney stones, flank pain, cloudy urine or bad smell, denies being sexually active.
Musculoskeletal: Denied joint pain or stiffness.
Neurological: Denied drowsiness, or focal weakness, no syncope, no seizures, no visual or speech disturbances, no impaired mobility, no memory deficit.
Mental: No anxiety, no depression, no memory problems, denied trouble concentrating.
Integumentary: Denies pruritus, bruises or rash.
OBJECTIVE
Physical Exam
Vitals Signs: Temp (Axillary): 102.20F. BP-sitting L: 108/66 mmHg (BP cuff size: Regular). Pulse Rate-Sitting: 92 bpm. (Regular rhythm). RR: 18 per min. Height 4”6”, Weight: 85lbs. BMI: 20.5 Kg/m2 (normal) 50 percentile. Oxygen Saturation: 99 %. Pain Scale/Rate: 5/10.
General appearance: Patient normal percentile according height and weight, properly dressed, speech clear and appropriate, cooperative to the interview, alert, oriented in place, person, time. Discomfort due to the pain is reflected in his face and posture. Well hydrated, well nourished
Skin: Skin normal turgor, no bruises, and no changes in moles. No visible or palpable lesions or rashes, no cyanosis.
Lymph nodes: Left periauricular adenitis, no palpable cervical, supraclavicular, axillary or inguinal nodes.
HEENT:
Head: Normocephalic, normal face symmetry. Scalp with no lesions, no tenderness. Hair distribution according to her age. Temporomandibular joint full ROM without clicks o pain bilaterally. No frontal or maxillary sinus tenderness.
Face: Symmetric facial expression, no deformities, tenderness to palpation over maxillary sinuses, no periorbital edema, no changes in color pigmentation, no involuntary movements.
Eyes: EOMs intact. Brows and lashes normal configuration, no edema, White sclera, no lesions;
PERRLA.
Ears: Right ear with normal appearance, no erythema, tympanic membrane pearly grey, translucent with no bulging, no discharge. Left tympanic membrane erythematous and bulging with diminished bony landmarks. No purulent drainage observed . Painful to palpation of mastoid bone. Nose: Bilateral nares patent pink coloration without rhinorrhea; no edema of the turbinate found. Septum midline
Mouth: pink, moist mucous membranes. No missing or decayed teeth. Throat: Pink normal oropharynx erythematous, without tonsillar edema or exudate; uvula midline.
Neck: Flexible; denied pain. Thyroid not visible or palpable. No carotid bruits and no jugular vein distention.
Chest/Lungs: Chest wall symmetrical, no use of accessory muscles note, breath sounds are clear, no wheezing, rhonchi, or crackle, no prolonged expiration noted in the upper/lower lung fields. No nipple discharges or abnormal lump noted, no axillary lymphadenopathies.
Cardiovascular: S1 and S2 regular rate and rhythm with no splitting. Carotid with no bruits. No JVD. No thrills. No rubs. Peripheral pulses present in all extremities. Capillary refill less than 3 seconds. No edema.
Abdomen: Skin without lesions, or rashes. Abdomen flat and symmetric with no lumps or bulges. Bowel sounds presents in the 4 quadrants. Percussion reveals tympany over all quadrants. No tenderness no guarding in any quadrant with palpation. No palpable masses or hepatosplenomegaly.
Genitals/Urinary: Penis circumcised without lesions, urethral meatus normal location without discharge, testis and epididymis with normal size without masses, scrotum without lesions. Tanner Stage 2.
Musculoskeletal: Normal passive and active ROM in upper and lower extremities. No focal
deficit, no joint inflammation or deformities noted.
Neurologic: Patient alert and oriented in person, time and place, cranial nerves II-XII intact. No focal motor or sensory deficits. Coordination, sensation, and reflexes are intact.
ASSESSMENT
Acute Otitis Media, Left Ear (H65.02): is diagnosed in patients with acute onset, presence of middle ear effusion, physical evidence of middle ear inflammation, and symptoms such as pain, irritability, or fever. Acute Otitis media is usually a complication of Eustachian tube dysfunction that occurs during a viral upper respiratory tract infection. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms isolated from middle ear fluid. (Domino, Baldor, Golding & Stephens, 2017) .According to (Burns, 2017) It is essential accurately diagnose Otitis media to reduce overtreatment and antibiotic resistance, and There are different types AOM, Suppurative effusion of the middle ear, other is Bullous myringitis AOM in which bullae form between the inner and middle layers of the TM and bulge outward, persistent when AOM that has not resolved when antibiotic therapy has been completed or AOM recurs within days of treatment and recurrent when Three separate bouts of AOM within a 6-month period or four within a 12-month period; often a positive family history of Otitis media and other ENT disease, to support this diagnosis Left tympanic membrane Erythematous and bulging with diminished light reflex is showed in the ear exam
Differential diagnosis
Diffuse Otitis Externa (OE), commonly called swimmer's ear, is a diffuse inflammation of the external auditory canal (EAC) and can involve the auricle, or both. Inflammation is evidenced as simple infection with edema, discharge, and erythema; furuncles or small abscesses that form in hair follicles; or impetigo or infection of the superficial layers of the epidermis. OE results when the protective barriers in the EAC are damaged by mechanical or chemical mechanisms. OE.The most common causative organisms are Pseudomonas aeruginosa and Staphylococcus aureus (Buttaro, Trybulski, Polgar-Bailey & Sandberg-Cook, 2017). This diagnosis was ruled out based on no complaints of itching and symptoms of the disease.
Other differential diagnosis to take into consideration: The assessment conducted also rules out mastoiditis, cholesteatoma, otitis externa and otitis media with effusion.
Mastoiditis: It is an inflammatory of the mastoid in the temporal bone. The mastoid is a structure contiguous to the middle ear cleft and an extension of it. The clinical presentation is characterized by symptoms involving the middle ear such as fever, local pain, and conductive hearing loss. Typically, patients with this illness presented with fever, irritability, lethargy, swelling of the ear lobe, Redness and tenderness behind the ear, Drainage from the ear, Bulging and drooping of the ear (Burns et al, 2017). This is also not the case were presented, so it is discarded.
Miryngitis: These patients may have no symptoms attributable to the middle ear.On otoscopy there is erythema and injection of the tympanic membrane in the neutral position without other features of otitis media.
PLAN
No labs /Diagnostic test ordered
Pharmacological treatment:
Amoxicillin 500 mg 1 tab PO every 12 hours for 10 days (dosage (90mg/kg/day)
Acetaminophen 325 mg 1 cap PO every 4-6 hours PRN for fever or pain (dosage 10-15 mg/kg orally/rectally every 4-6 hours when required, maximum 75 mg/kg/day)
Non-pharmacological measures:
Patient’s mother has been educated on increasing the fluids and to uses less clothing. Popsicles and iced drinks are helpful to recover the body fluids that are lost during fevers because of sweating. Sponging is a method that can be used to reduce the fever along with the Acetaminophen prescribed. Patient’s caregivers were recommended to not sponge the child without giving Acetaminophen first.
Education:
-Avoid Q tip use.
-Proper Nutrition/rest
-Proper use of antibiotics is important and misunderstanding of technique can lead to treatment failure. For this reason, placement of drops should be taught in the office. Xylitol, probiotics,
herbal ear drops, and homeopathic interventions may be beneficial in reducing pain duration, antibiotic use, and bacterial resistance.
-Even though an ear infection is not transmissible, the causative biological agents (bacteria or virus) are often passed from person to person. It’s very important to take into account the following measures: vaccination against Pneumococcal injection your child with a pneumococcal conjugate vaccine to protect against several types of pneumococcal bacteria. This type of bacteria is the most common cause of ear infections.
-Practice routine hand washing and avoid sharing food and drinks, especially if your child is exposed to large groups of kids in day care or school settings.
-Avoid second-hand smoke. Recommendation against cigarette smoke exposure is one of the most important measure to practice preventing Otitis media.
Referral/Follow up: No referral needed at this moment. Monitoring 48 hours after therapy if experiencing worsening symptoms, if current treatment is not successful to treat the condition, or new symptoms/side effects develop.
References
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