SOAP NOTE – Otitis Media Right Ear

“My right ear hurts, and I can’t hear well from it.”

A.C. is a 7-year-old male accompanied by his mother, presenting with a 2-day history of right ear pain and muffled hearing. The pain is sharp, intermittent, and worsens at night. His mother reports associated symptoms of low-grade fever (maximum 100.8°F), increased irritability, and decreased appetite. No vomiting or diarrhea. No recent trauma. The patient had a cold about one week ago, which has mostly resolved, except for a lingering runny nose. No history of similar episodes requiring surgical intervention. No known exposure to sick contacts in school.

Children’s Tylenol (acetaminophen) 160 mg/5mL, 5 mL every 6 hours as needed for fever and pain.

Allergies: No known drug allergies

Medication Intolerances:

None reported

Chronic Illnesses/Major traumas

None reported

Hospitalizations/Surgeries

No history of hospitalizations or surgeries

No history of diabetes, HTN, asthma, cancer, TB, thyroid, psychiatric, or kidney disorders.

No history of recurrent ear infections. A.C.’s father has hypertension, and the mother is healthy. No family history of TB, cancer, or hereditary hearing loss.

Lives with both parents and one younger sibling. Attends elementary school. Up to date on vaccinations. No tobacco, alcohol, or drug exposure. Safe home environment.

Mild fatigue and irritability, low-grade fever.

No chest pain or palpitations.

No rash, bruising, or lesions.

No cough or shortness of breath; residual nasal congestion.

No visual disturbances.

Decreased appetite, no vomiting or diarrhea.

Right ear pain, decreased hearing, no drainage.

Normal urination.

Mild nasal congestion, sore throat resolved.

No pain or swelling.

No concerns reported

No dizziness, syncope, or seizures.

No night sweats, gland swelling, or endocrine complaints.

No depression, anxiety, or sleep disturbance apart from illness.

Well-nourished child in mild distress due to ear pain. Alert and interactive.

Warm, dry, intact. No lesions or rash.

Head is normocephalic, atraumatic, and without lesions. Eyes: PERRLA. EOMs intact. No conjunctival injection. Ears: The right tympanic membrane is erythematous, bulging, and without normal light reflex; limited mobility on pneumatic otoscopy. Left tympanic membrane normal. No discharge noted. Nose: Clear mucus and slight swelling of the nasal mucosa. Wet oral mucosa. Tonsils are not erythematous or swollen.

Regular rate and rhythm. No murmurs or gallops.

Clear to auscultation bilaterally. No wheezing or rales.

Soft, non-distended. Normal bowel sounds. No tenderness or masses.

Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling or discoloration of the skin.

Bladder is not distended, normal urination.

Normal gait. No joint swelling or pain.

Alert, appropriate affect. Normal speech and coordination.

Appropriate behavior for age. No concerns noted.

Not required for routine acute otitis media unless complications are suspected.

Pneumatic otoscopy confirms decreased tympanic membrane mobility on the right side.

o    1- Acute Otitis Media (AOM) – Right Ear (ICD-10 Code: H66.91)

The diagnosis is most probably Acute Otitis Media because this condition presents symptoms such as right-sided earache, low-grade fever, hearing loss, and tympanic membrane (TM), which appears to be bulging with no light reflex. These signs manifest after a severe viral upper respiratory illness, which is a frequent reason for AOM because of eustachian tube dysfunction and consequent fluid retention in the middle ear (Danishyar & Ashurst, 2023). This patient is presenting with a sudden onset of pain and fever, and on pneumatic otoscopy, the diagnosis of AOM would seem to be most likely.

o    2- Otitis Media with Effusion (OME) (ICD-10 Code: H65.91)

OME is more common in children and presents with middle ear effusion but without signs of acute infection. It may follow AOM or viral infection and is mostly recognized by hearing loss or fullness in the ear as opposed to pain or fever (Searight et al., 2023). In this case, there is ear pain, fever, and inflammation of the TM, which cannot be explained by the OME diagnosis only. While middle ear fluid might be present, the inflammatory signs indicate an active infection rather than a sterile effusion.

o    3- Otitis Externa (OE) ICD-10 Code: H60.91

Otitis externa or “swimmer’s ear” involves inflammation of the external auditory canal. It is commonly associated with ear pain worsened by manipulation of the tragus or pinna and may involve canal swelling or discharge (Medina-Blasini & Sharman, 2023). This patient lacks such features: the pain is localized internally, and the canal is patent and non-tender, making OE a less likely differential in this case.

Diagnosis

o    Acute Otitis Media (Right Ear) (ICD-10 Code: H66.91)

The final diagnosis arrived at is Acute Otitis Media of the right ear. This is supported by a bulging erythematous TM with reduced mobility, a history of a recent URI, fever, and otalgia. The pneumatic otoscopy that reveals purulent middle ear effusion enhances this diagnosis and strengthens the conviction of its accuracy

§  Further testing

Routine laboratory testing is not required for uncomplicated AOM. Additional diagnostics may be considered if the patient does not improve after 48–72 hours or presents with signs of complications such as mastoiditis or persistent high fever.

§  Medication

First-line treatment is high-dose amoxicillin at 90 mg/kg/day, divided into two doses. For this child, weighing approximately 24 kg, the recommended dose is 540 mg twice daily. The appropriate prescription is Amoxicillin 400 mg/5 mL oral suspension, dosed at 6.75 mL BID for 10 days (Akhavan et al., 2023). To manage fever and pain, Acetaminophen 160 mg/5 mL, dosed at 5 mL every 6 hours as needed, is advised.

§  Education

The caregiver should be thoroughly educated on the importance of completing the full course of antibiotics, even if symptoms improve before completion. Warning signs requiring immediate reassessment include persistent fever beyond 72 hours, increasing ear pain, swelling behind the ear, or signs of systemic illness. Preventative advice includes minimizing water entry into the affected ear, practicing good hand hygiene, and avoiding exposure to second-hand smoke, all of which can reduce recurrence risk. It is also helpful to explain the typical course of AOM and set expectations regarding recovery.

§  Non-medication treatments

Supportive care includes using warm compresses over the affected ear to ease discomfort, ensuring the child stays hydrated, and promoting rest. Sleeping with the head elevated may also help relieve pressure in the middle ear and improve drainage.

The child tolerated the physical examination without complication. The caregiver demonstrated an understanding of the diagnosis and treatment plan, including medication administration, symptom monitoring, and appropriate use of supportive measures. A follow-up appointment is scheduled for 10 days or sooner if there is no improvement or worsening of symptoms. The family expressed confidence in managing care at home based on the instructions provided.