APA format in a SOAP Note format.  1 page long with questions as to

APA format in a SOAP Note format.  1 page long with questions as to which diagnosis would be accurate and why.  I have included the references I need 3 peer review articles to be included



Patient Information:

Initials
: JS  
Age
: 11   
Sex
: M  
Race
: Caucasian

SJ

CC: 
Patient complaining of a mild right earache for the last two days and trouble hearing from that ear.

HPI
: James Jones is an 11 year old Caucasian male who presents to the clinic with complaints of a right earache for the last two days. The patient reports worsening pain at night when trying to fall asleep and difficulty hearing out of that ear.  The patient rates is earache pain 5/10 and describes it as sharp and constant. The patient has taken 600mg ibuprofen with minimal relief of pain. The patient reports that he has been spending a lot of time swimming in the pool this summer.

Current Medications
:

1.  Ibuprofen 600mg PRN for earache pain


Allergies: 
NKA


PMHx
: Up to date on all immunizations. No significant PMH.


Soc Hx
: Patient lives with two siblings and supportive parents in a safe neighborhood in Boston. The patient is currently in middle school and enjoys playing soccer, fishing with his dad and swimming in his pool during the summer. 


Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No other significant family history.


ROS
: 


GENERAL: No fever, fatigue or chills. No weight loss. 


HEENT: 
Eyes:
  No visual loss, blurred vision, double vision or yellow sclerae. 
Ears: 
Patient reporting pain in right ear and hearing loss.
 Nose,

Throat:
  No sneezing, congestion, runny nose or sore throat. 


SKIN: No rashes or itching.


RESPIRATORY:  No shortness of breath, cough or sputum.


GASTROINTESTINAL:  No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.


NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.


LYMPHATICS:  No enlarged nodes. No history of splenectomy.


ALLERGIES:  No history of asthma, hives, eczema or rhinitis.


O.


GENERAL: Patient comes to the clinic with his grandmother, patient appears uncomfortable, is rubbing his right ear and having difficulty hearing. 


HEENT: PEERLA. 
Ears:
 Right ear canal is erythematous and edematous with pus present, tympanic membrane is difficult to visualize. Hearing difficulty with right ear. Left ear canal is intact without erythema or edema, tympanic membrane is clear and intact. 
Nose
: Nose is patent without any rhinorrhea. 
Throat:
 Oropharynx is clear, without erythema or exudates, mucous membranes are moist, pink and intact. (Sullivan, 2012).


SKIN: Skin color is normal for patient, intact, without rashes or lesions. Skin turgor is good. 


RESPIRATORY: LS CTA bilaterally, no sternal retractions noted.


GASTROINTESTINAL: Abdomen is soft, nontender, nondistended. + BS in all quadrants. No bruits noted. No splenomegaly or masses present. 


NEUROLOGICAL: Cranial ...

1. APA format in a SOAP Note format. 1 page long with
questions as to which diagnosis would be accurate and why. I
have included the references I need 3 peer review articles to be
included



Patient Information:

Initials
: JS
Age
: 11
Sex
: M
Race
: Caucasian

SJ

CC:
Patient complaining of a mild right earache for the last two days
and trouble hearing from that ear.

HPI
: James Jones is an 11 year old Caucasian male who presents to
the clinic with complaints of a right earache for the last two
days. The patient reports worsening pain at night when trying to
fall asleep and difficulty hearing out of that ear. The patient
rates is earache pain 5/10 and describes it as sharp and constant.
The patient has taken 600mg ibuprofen with minimal relief of
pain. The patient reports that he has been spending a lot of time
swimming in the pool this summer.

Current Medications

2. :

1. Ibuprofen 600mg PRN for earache pain


Allergies:
NKA


PMHx
: Up to date on all immunizations. No significant PMH.


Soc Hx
: Patient lives with two siblings and supportive parents in a safe
neighborhood in Boston. The patient is currently in middle
school and enjoys playing soccer, fishing with his dad and
swimming in his pool during the summer.


Fam Hx
: Maternal grandmother died of a stroke at the age of 70. No
other significant family history.


ROS
:


GENERAL: No fever, fatigue or chills. No weight loss.


HEENT:
Eyes:
No visual loss, blurred vision, double vision or yellow
sclerae.

3. Ears:
Patient reporting pain in right ear and hearing loss.
Nose,

Throat:
No sneezing, congestion, runny nose or sore throat.


SKIN: No rashes or itching.


RESPIRATORY: No shortness of breath, cough or sputum.


GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood.


NEUROLOGICAL: No headache, dizziness, syncope, paralysis,
ataxia, numbness or tingling in the extremities. No change in
bowel or bladder control.


LYMPHATICS: No enlarged nodes. No history of splenectomy.


ALLERGIES: No history of asthma, hives, eczema or rhinitis.


O.


GENERAL: Patient comes to the clinic with his grandmother,
patient appears uncomfortable, is rubbing his right ear and
having difficulty hearing.

4. HEENT: PEERLA.
Ears:
Right ear canal is erythematous and edematous with pus
present, tympanic membrane is difficult to visualize. Hearing
difficulty with right ear. Left ear canal is intact without
erythema or edema, tympanic membrane is clear and intact.
Nose
: Nose is patent without any rhinorrhea.
Throat:
Oropharynx is clear, without erythema or exudates, mucous
membranes are moist, pink and intact. (Sullivan, 2012).


SKIN: Skin color is normal for patient, intact, without rashes or
lesions. Skin turgor is good.


RESPIRATORY: LS CTA bilaterally, no sternal retractions
noted.


GASTROINTESTINAL: Abdomen is soft, nontender,
nondistended. + BS in all quadrants. No bruits noted. No
splenomegaly or masses present.


NEUROLOGICAL: Cranial nerves II to XII are grossly intact
w/out focal neurological defecits (Sullivan, 2012).


LYMPHATICS: No enlarged nodes.


ALLERGIES: No known allergies. No history of asthma, hives,
eczema or rhinitis.

5. Diagnostic results
: Include any labs, x-rays, or other diagnostics that are needed
to develop the differential diagnoses (support with evidenced
and guidelines)


Otoscopy:
Otoscopy of the ear canal demonstrated erythema, swelling and
there was difficulty visualizing the tympanic membrane as there
was watery discharge present. According to Lieberthal (2013),
otoscopy is usually sufficient enough to reach the diagnosis of
otitis externa in children, however, certain cases require
additional diagnostics, especially when occurring in infants
presenting with fever.


Labs:
N/A


A
.


Differential Diagnoses:

1. Otitis externa - I chose this as the primary diagnosis because
of the patient’s presenting symptoms and the context in which
the patient experienced the symptoms. The patient complained
of worsening ear pain and hearing loss in the right ear. The
patient also reported that he had been swimming in the pool a
lot recently. According to Wald (2018), otitis externa often
occurs in children after swimming, causes pain and conductive
hearing loss if pus or discharge is present and clinical findings

6. include an erythematous, edematous ear canal and difficulty
visualizing the tympanic membrane.


Acute otitis media- Acute otitis media is another possible
diagnosis for this patient because of his presenting symptoms.
According to Thomas (2014), acute otitis media generally
occurs in patients after a respiratory tract infection and
symptoms can include fever, fatigue or malaise. Additionally,
Thomas (2014) discusses how purulent discharge is usually
present with a bulging tympanic membrane. However, the
patient did not report respiratory tract infection related
symptoms and was not febrile.

Otitis media with effusion- Otitis media with effusion cannot be
ruled out because there is often discomfort in the affected ear
with conductive hearing loss, however, there is not usually any
purulent fluid in the canal, nor is it associated with swimming
(Thomas, 2014).

Upper respiratory infection- upper respiratory infection is
another possible diagnosis for this patient as it can cause
blocking or painfulness in the ear as well as an erythematous
tympanic membrane (Pettigrew, 2011). Additionally, upper
respiratory infections often times precede otitis externa or other
ear infections.

Furunculosis- Furunculosis is another possible diagnosis for this
patient. Furunculosis is


usually an infected hair follicle in the ear canal that leads to
otalgia and tenderness of the

ear which this patient presented with. However it is not too
likely as it usually affects the

7. cartilage of the year and does not lead to conductive hearing
loss (Ibler, 2014).


References


Ibler, K., & Kromann, C. (2014). Recurrent furunculosis –
challenges and management:

a review.
Clinical, Cosmetic and Investigational Dermatology, 7
, 59-64.

doi:10.2147/ccid.s35302

Lieberthal, A. S., Carroll, A. E., Chonmaitree, T., Ganiats, T.
G., Hoberman, A., Jackson,

M. A., . . Tunkel, D. E. (2013). The diagnosis and management
of acute otitis

media.
Pediatrics, 131
(3), 964-999. Retrieved September 25, 2018, from



http://pediatrics.aappublications.org/content/pediatrics/131/3/e9
64.full.pdf


Pettigrew, M. M., Gent, J. F., Pyles, R. B., Miller, A. L.,
Nokso-Koivisto, J., &

8. Chonmaitree, T. (2011). Viral-bacterial interactions and
risk of acute otitis

media complicating upper respiratory tract infection.
Journal of Clinical

Microbiology, 49
(11), 3750-3755. doi:10.1128/jcm.01186-11

Sullivan, D. D. (2012).
Guide to clinical documentation (2nd ed.).
Philadelphia, PA: F.

A. Davis.


Thomas, J. P., Berner, R., Zahnert, T., & Dazert, S. (2014).
Acute Otitis Media—a

Structured Approach.
Deutsches Ärzteblatt International,

111
(9), 151-160.

Retrieved September 25, 2018, from


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965963/pdf/Dt
sch_Arztebl_Int-

111-
0151.pdf.


Wald, E. R. (2018). Acute otitis media in children: diagnosis.

9. UpToDate
. Retrieved

September 25, 2018, from
https://www.uptodate.com/contents/acute-otitis-media-