Episodic/Focused SOAP Note
Patient Information:
Initials: A.M. Age: 3 years old Sex: Female Race: White
S.
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.
ROS:
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.
O.
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.
HEENT:
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.
Neurologic:
Mental status: Lacks concentr
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