Pediatric Ear Pain: A Comprehensive Episodic SOAP Note and Differential Diagnosis
Case Study 3: Focused Ear Exam
Amy, a 3-year-old girl is brought to your office by her mother because she has a fever and complains that her ear hurts. She has no significant medical history. The child is not pleased to be in the provider\’s office and has been crying. Her mother explains that she developed a cold about 3 days ago with sniffles. As she cries, she continues to cough and has yellowish nasal discharge.
With regard to the case study, you were assigned:
- Review this week\’s Learning Resources and consider the insights they provide.
- Consider what history would be necessary to collect from the patient.
- Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\’s condition. How would the results be used to make a diagnosis
- Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\’s differential diagnosis and justify why you selected each.
Episodic/Focused SOAP Note
Initials: A.M. Age: 3 years old Sex: Female Race: White
CC (chief complaint): “My daughter has a fever and complains of a hurting ear. She developed a cold about 3 days ago with sniffles, has a yellowish nasal discharge and a cough.”
HPI: Amy is a 3-year-old female patient who has been brought to the clinic accompanied by her mother. As reported by the mother, Amy developed a cold about 3 days ago, has a cough, and presents with yellowish nasal discharge. These symptoms started 3 days ago. She further indicates that she has not given her daughter any medications to reduce the pain.
Current Medications: None.
Allergies: No known drug or food allergies.
PMHx: All immunizations taken according to schedule. She was hospitalized due to malaria complications at the age of two years.
Soc Hx: Amy is physically active. Both parents deny alcohol or cigarette consumption.
Fam Hx: Both parents are alive with no serious health diagnosis. Grandparents are alive too. Maternal grandmother has type 2 diabetes.
GENERAL: Reports fever, denies abnormal weight loss.
HEENT: Eyes: Denies blurred vision. Ears: Reports ear pain. Reports hearing impairment. Reports yellowish discharge from the ears. Nose: Reports a yellowish nasal discharge, reports sniffles. Throat: Reports a cough.
SKIN: Denies itching or rash.
CARDIOVASCULAR: Denies chest pain or chest discomfort.
RESPIRATORY: Reports a cough. Denies shortness of breath. Reports a yellowish nasal discharge.
GASTROINTESTINAL: Denies diarrhea, abdominal pain, or vomiting.
GENITOURINARY: Denies urination-related issues.
NEUROLOGICAL: Denies a headache or dizziness. Reports difficulty sleeping due to ear pain.
MUSCULOSKELETAL: Denies joint pain, muscle ache, or back pain.
HEMATOLOGIC: Denies abnormal bleeding or other blood-related disorders.
LYMPHATICS: Denies abnormal enlarged nodes.
PSYCHIATRIC: Denies history of any mental disorders.
ENDOCRINOLOGIC: Denies reports of abnormal night sweats.
ALLERGIES: Denies a history of food or drug allergy.
VII. Physical examination
Vital signs: Respiratory rate: 18 breaths per minute, BP; 105/60, temperature; 104oF, pulse; 90 beats per minute, weight; 14.3 kg.
General appearance: Amy is unsettled. She is crying uncontrollably due to ear pain. She continues to cough while crying.
Skin: Absence of lesions, rashes, or sores. Warm and intact.
Head: No evidence of trauma or masses. It is normocephalic. No evidence of alopecia.
Eyes: Conjunctivae are clear. No evidence of hemorrhage.
Ears: The eardrum is swollen and erythematous. Yellow fluid is seeping from the ear. The tympanic membrane is dark-pink in color.
Nose: Septum is positioned midline. Nasal mucosa in moist, hairy, and pink. Evidence of a yellowish nasal discharge.
Throat: Absence of mouth lesions or sores. Throat is erythematous.
Neck: No swelling, thyroid is palpable.
Nodes: Absence of inguinal swelling.
Breasts: No discharge or abnormal masses.
Chest: Absence of rubs, wheezes, or rhonchi.
Heart: S1, S2. No murmur or gallop. PMI is visible. Absence of edema. Heart rhythm is normal.
Abdomen: No abdominal tenderness.
Back/spine: Absence of mobility challenges or deformities.
Extremities: Absence of tremor, joint tenderness, or swellings in all extremities.
Genitalia/Rectal: Absence of vaginal discharge or inflammation.
Mental status: Lacks concentration due to the discomfort caused by the pain.
Cranial nerves: Evidence of visual fields on all cranial nerves.
Motor: Absence of muscle rigidity. Presence of good balance.
Sensory: Sensitive to touch and pain
- Otitis media with effusion (primary diagnosis)
- Acute otitis media
- External otitis
- Bullous myringitis
Bickley, L., Szilagyi, P., Hoffman, R., & Soriano, R. (2020). Bate’s guide to physical examination and history taking (Lippincott Connect). 13th ed. Philadelphia: Wolters Kluwers.
Dains, J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby.
Satoh, C., Toizumi, M., Nguyen, H., Hara, M., Bui, M. X., Iwasaki, C., Takegata, M., Kitamura, N., Suzuki, M., Hashizume, M., Dang, D. A., Kumai, Y., Yoshida, L. M., & Kaneko, K. I. (2021). Prevalence and characteristics of children with otitis media with effusion in Vietnam. Vaccine, 39(19), 2613–2619. https://doi.org/10.1016/j.vaccine.2021.03.094