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NURS 6541 Week 3 SOAP Note

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SUBJECTIVE DATA: Chief Complaint (CC): “pulling at left ear, irritable.” History of Present Illness (HPI): The patient is a 2-year and 6-month old Caucasian male who presents with his mother. T ... he mother states that the child recently had an upper respiratory infection one week ago and that she believes the child may have an ear infection because he keeps pulling at his left ear and has been irritable for the past two days. She states that the child does not complain of pain when asked but has not Review of Systems: General: denies fevers, night sweats, chills, loss of appetite, fatigue, weakness, or weight loss. Child has been showing irritability in behavior x 4 days. HEENT: denies vision loss, pain in eyes, sensitivity to light, discharge from ears, decreased hearing, postnasal drip, nasal congestion, nosebleed, coughing, and difficulty or pain swallowing. Mother states that child recently recovered from a respiratory infection. Also states that child has been pulling at left ear x2 days. CV: denies chest pains, SOB on exertion, bluish or grayish color around eyes, skin, lips, or nails. Resp: complains of occasional wheezing and SOB, but no more than usual with child’s reactive airway disease. Denies cough or chest congestion. GI:References Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., Blosser, C. G., & Garzon, D. L. (Eds.). (2017). Pediatric primary care (6th ed.). St. Louis, Missouri: Elsevier. Waitzman, A. A., (2018). Otitis externa. Retrieved from https://emedicine.medscape.com/article/994550-overview Wald, E. R. et al, (2013). Clinical practice guideline on diagnosis and management of acute bacterial sinusitis in children one to 18 years of age. Pediatrics, 132(1), e262–e280. Retrieved from http://pediatrics.aappublications.org/content/pediatrics/132/1/e262.full.pdf [Show More]

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