Soap Note – Pediatrics – Acute Otitis Media

ID:

Client’s Initials: HC | Age: 8 | Race: African American | Gender: Male | Date of Birth: April 3, 2016

Insurance: Medicaid | Marital Status: Minor | ID: 1190564 | Encounter Date: 06/07/24

Subjective:

CC: “My right ear hurts a lot.”

HPI:

HC, an 8-year-old African American male brought in by his mother, presents with a chief complaint of severe right ear pain. Per the mother’s report, the pain began two days ago and has progressively worsened. The patient complains of sharp, stabbing pain localized to the right ear. He denies any recent trauma to the ear or upper respiratory symptoms. However, the mother mentioned that he had a cold about a week ago. Pain worsens with movement and is accompanied by intermittent low-grade fever. There are no alleviating factors reported. The patient has not received any treatment at home. The severity of the pain has been interfering with his sleep and daily activities, prompting this visit to seek medical attention.

Past Medical History:

Medical problem list: No history of medical problems reported.
Preventative care: HC has received regular vaccinations in accordance with his age and the recommended immunization schedule. His recent vaccinations are as follows: The annual influenza vaccine he took in the year 2023 to prevent flu infection likely to be experienced during that season. Also, he also got vaccinated with Tdap in 2021 to prevent bacterial infections such as Tetanus, diphtheria, and pertussis. Other vaccinations administered to early childhood HC include MMR, varicella, hepatitis A and B, polio, PCV13, and Hib.
Surgeries: No previous surgeries reported.
Hospitalizations: No history of hospitalizations mentioned

Allergies: There are no known reported drug, food, or environmental allergies.

Medications: HC is not on any current medications.

Family History: The mother reveals that HC’s father has had hypertension and type 2 diabetes in the past. Seasonal allergy and asthma are other health concerns she has been experiencing, particularly during the spring seasons. HC is the second child in a family of three, the first of which is a healthy older sister who has no underlying diseases or illnesses. As for the members of the extended family, the paternal grandfather has a history of stroke, while the paternal grandmother has a history of hypertension. On the maternal side, grandfather had a heart disease, whereas grandmother had breast carcinoma.

Social History: HC’s family comprises five members, which include himself, his mother, his father, and an elder sister, and they reside in a suburban area. He is fascinated by going to school, is currently in the third grade, and has many friends. He engages in hands-on learning through sports, such as soccer and the Science Enrichment Club. There is no family history of smoking, alcohol, or illicit drug use. He eats proper, healthy meals and loves to participate in sporting activities. He has a good family, he has a home that is safe for him, and his challenges are recognized, and his family supports him.

Safety: The mother reports that her children are safe at home, and there are no child hazards around. She makes sure that they use car seats and seat belts for every journey they undertake. Smoking alarms and carbon monoxide alarms are also put in and regularly checked. Contents, such as medications and cleaning supplies, are locked away to avoid the child’s direct access. The family has an escape plan each time there is an emergency, and HC is aware of basic safety precautions, such as not talking to any stranger and making a 911 call. The family does not own any firearms and keeps none in the house. She also keenly checks on his safety during sporting activities, taking time to ensure he puts on protective gear.

Review of Systems

Constitutional: Reports general body weakness. No weight loss, chills, or fever was reported.

Eyes: No vision changes, redness, or discharge.

Ears/Nose/Mouth/Throat: Reports right ear pain. No nasal congestion, sore throat, or oral lesions.

Cardiovascular: No chest pain, palpitations, or edema.

Pulmonary: No cough, shortness of breath, or wheezing.

Gastrointestinal: No nausea, vomiting, diarrhea, or abdominal pain.

Genitourinary: No dysuria, frequency, or hematuria.

Musculoskeletal: No muscle pain, joint pain, or swelling.

Integumentary & breast: No rashes, lesions, or breast changes.

Neurological: No headaches, dizziness, or seizures.

Psychiatric: No anxiety, depression, or behavioral changes.

Endocrine: No polyuria, polydipsia, or heat/cold intolerance.

Hematologic/Lymphatic: No bruising, bleeding, or lymphadenopathy.

Allergic/Immunologic: No known allergies, recent infections, or immune system disorders.

Objective

Height 51 inches (129.5 cm) (75th percentile) | Weight 60 lbs (27.2 kg) (70th percentile) | BMI 16.3 kg/m² (60th percentile)

Labs, radiology, or other pertinent studies:

 An otoscopic examination conducted today reveals erythema and bulging of the right tympanic membrane, consistent with acute otitis media.

 No further labs or radiological studies were conducted during this encounter.

Physical Exam

General Survey: HC is an 8-year-old African American male who appears to be in moderate distress due to ear pain. He is sitting upright on the examination table, holding his right ear and occasionally grimacing. He is alert and oriented, responding appropriately to questions. His skin color is appropriate for his ethnicity, with no signs of cyanosis or pallor. There are no obvious signs of respiratory distress. He is well-nourished and appropriately developed for his age.

Head: Normocephalic and atraumatic. No signs of trauma, lesions, or deformities. Hair distribution is normal.

Eyes: Pupils equal, round, and reactive to light. Extraocular movements are intact. Conjunctivae pink, sclerae white. No discharge or redness was noted. Visual acuity is grossly intact.

Ears: Right ear: External canal erythematous, edematous, with tenderness on manipulation. The tympanic membrane appears erythematous and bulging. Decreased mobility was noted with pneumatic otoscopy. Left ear: External canal and tympanic membrane appear normal.

Nose: Nares patent bilaterally, mucosa pink without discharge or polyps.

Mouth and Throat: Oral mucosa moist, pink, and intact. Oropharynx without erythema, exudates, or tonsillar enlargement. No signs of dental caries or oral lesions.

Neck: Supple without lymphadenopathy or thyromegaly. Trachea midline. No jugular venous distention or masses were palpated.

Cardiovascular: Regular rate and rhythm. No murmurs, rubs, or gallops. Radial pulse present, 92 bpm, regular, and bilaterally symmetrical.

Respiratory: The chest moves with respiration. The respiratory rate is 20 breaths per minute. There are no chest abnormalities or therapeutic marks. The trachea is centrally placed. There is no tactile fremitus. The chest is resonant on percussion. Vesicular breath sounds are heard on auscultation.

Abdomen: Moving with respiration. Umbilicus everted. Of normal fullness. Soft to touch. No tenderness. No organomegaly.Normoactive bowel sounds.

Musculoskeletal: Complete range of motion in each limb. No swelling, pain, or abnormalities were seen. Tone and strength unaltered.

Skin: Notably warm to touch. Looks dry, free of blemishes, rashes, or anomalies. No bruises or discolorations.

Neurological: The second to eleventh cranial nerves are largely undamaged. All extremities have normal motor function and sensibility. Typical movement.

Psychiatric: Proper mood and attitude. No symptoms of concern other than earache.

Endocrine: There are no indications of an enlarged thyroid or aberrant hair dispersion

Assessment

Differential Diagnoses

Tympanic Membrane Perforation: Perforation of the tympanic membrane is a clinical condition characterized by the tear or rupture of the eardrum. It can be caused by trauma, infection or variation in barometric pressure. HC has severe earache and apparent bulging of the tympanic membrane that may be suggestive of tympanic membrane rupture. Thus, there are no symptoms like purulent discharge, and hearing loss, which are characteristic of cases with tympanic membrane perforation (Koltsidopoulos & Skoulakis, 2020). Moreover, HC negates any history of recent injury or trauma to the ear or recent changes in the barometric pressure, which reduces the probability of this diagnosis.
Sinusitis: The paranasal sinuses refer to air-filled cavities within the bones surrounding the nose, and sinusitis is virus-induced inflammation of those cavities, usually following upper respiratory infections. While AOM targets the middle ear, sinusitis impacts an anatomical structure named the sinus that is contained in the facial bones that are in close association with the nasal cavity. Side effects of sinusitis may comprise facial discomfort and pressure, nasal stuffiness, as well as headache (Leung et al., 2020). Because HC can present with referred ear pain, sinusitis is a differential of HC; however, he lacks features that characterize sinusitis, such as facial pain on percussion, thick and colored nasal discharge, and nasal obstruction. Furthermore, signs comparable to sinusitis, such as facial pain or pressure-added headaches, are not present in HC’s condition. The decision not to order imaging studies like sinus X-rays or even CT scans also negates the possibility of sinusitis. Therefore, sinusitis should still be monitored if subsequent infection signs linger in HC or if more clinical data is revealed in further evaluation.
Temporomandibular Joint (TMJ) Dysfunction: Temporomandibular joint dysfunction involves pain or dysfunction of the temporomandibular joint, which connects the jawbone to the skull. While TMJ dysfunction primarily manifests as jaw pain or clicking with jaw movement, it can also cause referred pain to the ears, mimicking symptoms of AOM. TMJ dysfunction can cause referred ear pain, but in HC’s case, there are no clinical findings suggestive of TMJ dysfunction, such as tenderness over the temporomandibular joint, limitation of jaw movement, or clicking/popping sounds during jaw movement. Additionally, symptoms such as fever and tympanic membrane abnormalities would not be expected in TMJ dysfunction (Wadhokar & Patil, 2022). Therefore, while TMJ dysfunction is a differential to consider, the lack of supporting clinical features makes it less likely to be the main diagnosis for HC.

Diagnoses

Acute Otitis Media (AOM), ICD-10: H66.90

Acute otitis media (AOM) is a common infection of the middle ear, predominantly seen in pediatric patients. It typically follows upper respiratory infections and is characterized by inflammation and fluid accumulation in the middle ear space. HC initially developed severe right-sided ear pain and low-grade fever that lessened with movement. On general assessment, redness, swelling, and swelling with outward protrusion of the right tympanic membrane are observed, which suggests AOM. The clinical examination and investigations outlined above, coupled with the symptoms outlined, make this diagnosis very likely. The diverse clinical characteristics and the findings in HC are, in a way, consistent and reflect the general approach to acute otitis media diagnosis. Presenting signs and symptoms of severe sharp earache, erythematous bulging tympanic membrane, and fever in HC are characteristic features of AOM, as described by Suzuki et al. (2020). Therefore, the final diagnosis is acute otitis media.

Plan

Diagnostics:

Perform a thorough otoscopic examination to confirm the presence of AOM.
Consider tympanometry to assess middle ear function if the diagnosis is unclear.
No immediate lab tests or imaging studies are required unless symptoms persist or there are suspected complications (Hayashi et al., 2020).

Treatment:

First-line antibiotic treatment according to the severity of the streptococcal infection should be treated with amoxicillin 80-90 mg/kg/day but in two divided doses per day for 7-10 days.
If an allergy to penicillin is present then use another antibiotic like Cefdinir 14 mg/kg/day in one or two divided daily doses.
Paracetamol or any non-prescription pain relievers and antipyretics like Ibuprofen are advised to control pain and temperature. The dose depends on HC weight.
Suggest the usage of a warm compress on the receptor ear for additional analgesia (Suzuki et al., 2020).

Education:

Give HC’s mother information on the need to complete the course of the antibiotic even if HC starts finding discomfort.
Explain proper indications of complications like an increase in pain, swelling behind the ear, high temperature, or pus-like drop from the ear hole, and tell them to seek medical attention if they observe any of these complications.
Discuss how AOM normally develops and that the symptoms begin to resolve in a few days after the administration of antibiotics.
Encourage preventive measures such as avoiding exposure to secondhand smoke, practicing good hand hygiene, and ensuring HC stay up to date with vaccinations, including the flu and pneumococcal vaccines, which can help prevent ear infections (Hayashi et al., 2020).

Follow-Up:

Arrange and plan the next HC checkup after one week to ten days to confirm that the infection is clearing up.
Recommending that if HC is not relief from the symptoms within 48-72 hours of taking antibiotics or even deteriorates at any time, then the mother should bring him in.
Of the recurrent cases, where AOM actively recurs three or more times in a month or four or more in a year, the recommendation of an otolaryngologist to be considered, and in some extreme cases, tympanostomy tube placement may be administered (Hayashi et al., 2020).

Otitis Externa, ICD-10: H60.9

Otitis externa, or swimmer’s ear, is characterized as an acute infection and inflammation of the external auditory canal. It is normally related to water activities such as swimming, which subsequently results in skin breakdown- or maceration and infection. Because HC does not mention a history of exposure to water in the recent past, the erythematous and edematous changes in the external ear canal noted during the physical examination could point toward this particular diagnosis. However, the lack of specific tenderness on the manipulation of the auricle and the visible bulging of the tympanic membrane narrow the chances of this being AOM (Belli et al., 2023).

Plan

Diagnostics:

Perform an otoscopic examination to ascertain the diagnosis of otitis externa due to visualization of the ear canal and tympanic membrane.
Check the degree of redness, swelling, and any pus formed from the outer part of the ear canal.
Routine ECG, chest radiography, or other imaging is not needed in the early phase of management unless there are concerns for complications clinical worsening, or failure to respond to the initial ABCDEs (Belli et al., 2023).

Treatment:

Treat with topical antibiotics and cortical (Prescribe Ciprofloxacin and Hydrocortisone (Ciprodex) eardrops, 3 drops every 12 hours for 7 days.
If inflammation or edema is severe enough to make it difficult for the medicine to reach the affected area due to blockage of the ear canal, a wick may need to be placed in the ear canal.
Inform about the possibility of using painkillers, such as acetaminophen or ibuprofen, which are available without a prescription. Alternate according to the weight of the HC and follow the recommended dosing schedule.
Suggest the patient refrain from having water inside the ear during the process of treatment. However, it is recommended to use earplugs or a cotton ball with petroleum jelly when showering to minimize the penetration of water (Pantazidou et al., 2022).

Education:

Inform HC’s mother about the proper use of eardrop medicine and the need to follow the prescribed course of use.
Instruct on the proper administration of eardrops. Next, the head has to be tilted, the outer part of the ear has to be pulled up and backward to align the ear canal, and then the drops have to be instilled.
Give a brief description of precautions that should be taken to prevent ear injuries, such as removing objects that are lodged in the ear canal, avoiding water getting into the ears, and the use of ear plugs when swimming.
Advise about symptoms that point to a worsening infection or whether there is a complication, such as increased pain, ear fever, or redness around the ear, which should be checked by a doctor immediately (Pantazidou et al., 2022).

Follow-Up:

Make an appointment for a follow-up in a week to reevaluate HC’s status and make sure the illness is going away.
Suggest to the mother that HC be evaluated again if, within 48–72 hours of beginning treatment, his complaints do not improve or if they worsen at any point.
Discuss possible causes of recurring bouts of otitis externa, such as eczema or prolonged moisture exposure (Belli et al., 2023), and consider referring the patient to an otolaryngologist for additional assessment and treatment.

References

Belli, S., Cingi, C., & Sallavaci, S. (2023). Otitis Externa in Children and Auditory Impairment. In Hearing Loss in Congenital, Neonatal and Childhood Infections (pp. 195-202). Cham: Springer International Publishing. https://doi.org/10.1007/978-3-031-38495-0_14

Hayashi, T., Kitamura, K., Hashimoto, S., Hitomi, M., Kojima, H., Kudo, F., … & Yano, H. (2020). Clinical practice guidelines for the diagnosis and management of acute otitis media in children—2018 update. Auris Nasus Larynx, 47(4), 493-526. https://doi.org/10.1016/j.anl.2020.05.019

Koltsidopoulos, P., & Skoulakis, C. (2020). Otomycosis with tympanic membrane perforation: a review of the literature. Ear, Nose & Throat Journal, 99(8), 518-521. https://doi.org/10.1177/0145561319851499

Leung, A. K., Hon, K. L., & Chu, W. C. (2020). Acute bacterial sinusitis in children: an updated review. Drugs in Context, 9. https://doi.org/10.7573%2Fdic.2020-9-3

Pantazidou, G., Dimitrakopoulou, M. E., Kotsalou, C., Velissari, J., & Vantarakis, A. (2022). Risk Analysis of Otitis Externa (Swimmer’s Ear) in Children Pool Swimmers: A Case Study from Greece. Water, 14(13), 1983. https://doi.org/10.3390/w14131983

Suzuki, H. G., Dewez, J. E., Nijman, R. G., & Yeung, S. (2020). Clinical practice guidelines for acute otitis media in children: a systematic review and appraisal of European national guidelines. BMJ open, 10(5), e035343. https://doi.org/10.1136/bmjopen-2019-035343

Wadhokar, O. C., & Patil, D. S. (2022). Current trends in the management of temporomandibular joint dysfunction: a review. Cureus, 14(9). https://doi.org/10.7759%2Fcureus.29314

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1.) Create a PRETEND SOAP NOTE of Acute Otitis media for an 8-year-old male patient who came into the clinic with her mother. Initials: HC
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Soap Note – Pediatrics – Acute Otitis Media

3.) This is a focus SOAP NOTE, PLEASE use our SOAP NOTE TEMPLATE but only put details that are relevant to the chief complaint. ALSO, USE THE TITLE PAGE
4.) On the Assessment part put the rationale for why it is your main diagnosis and also rationales for the two differentials on why it is not the main diagnosis.
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Soap Note – Pediatrics – Acute Otitis Media