SOAP NOTE 3
APA format for SOAP NOTE 3 peer review articles 1 and half pages long please follow below instructions
Analyze the possible conditions from your colleagues’ differential diagnoses. Determine which of the conditions you would reject and why. Identify the most likely condition and justify your reasoning
case Study #3 Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked
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Cc: “Earache right ear”
HPI: Patient is an 11-year-old Caucasian boy who was brought in by his grandmother after complaining about having a mild earache for the past two days. Patient states that the pain is worse when he falls asleep and that it has become harder for him to hear, grandmother believes that he feels warm but has not taken his temperature
Medications: Patient does not take any medications
PMH: No significant illnesses, shots are up to date
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FH: No history of previous ear concerns no family history of ear disease. During the school year, patient lives at home with his mother, father and he does not have pets. Patient is staying with grandmother and grandfather most of summer
SH: Student in public school and is currently on summer break, has been spending a lot of time this summer in the pool per his grandmother that he is spending the summer with.
ROS: general: negative for chills fever currently
EENT: complains of mild right ear pain and mild hearing loss, denies tinnitus, denies pain in throat, or eye pain
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VS: T 100.8, P 94, R 18, BP 98/64
General: Patient appears to be in mild pain, holding head to right side slightly
HEENT: right tympanic membrane obscured, ear canal is read and has a musty odor from ear canal with small amount of watery drainage, head is normocephalic without signs of trauma, no nasal drainage, PEARL, no complaints of sore throat, no redness in throat
SKIN: Warm and dry, good skin turgor, prominent tan
NECK: No lymph node edema or signs of pain on palpation
NEUROLOGICAL: No complaints of headache or dizziness
Diagnostic results. WBC slightly elevated, low grade temp