NSG6435 Week 4 SOAP Note 2025.
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CC : Per mother: "He’s been complaining of his left ear hurting since last night at church. He said that it’s hard to hear from that ear too. His whole left ear was red like blood. He also has be... en coughing and complaining of a sore throat" HPI: The patient is a 7-year-old Caucasian male presenting in office with his mother with complaints of left ear pain that began last night while at church. The patient's mother reports that the entire ear appeared blood red. The patient complains of difficulty hearing from the affected ear, describing it as sounding "hard." The mother was able to visualize redness inside the ear by pulling it back slightly. The patient has also been coughing and complains of throat pain. The patient reports feeling warm, suggesting a possible fever, though his temperature was normal when checking. Patient’s symptoms have been present for 1 day. Patient’s mother denies sick contacts at home. Mother reports lying down on affected side makes ear pain worse. Mother has not tried overthe-counter medications. [Show More]
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