Pediatric SOAP

Subjective Data

Chief Complaint (CC):

Larry, a patient who is 3 years and 6 months old, presents to the clinic with a chief complaint of right ear pain for three days. His father, Thibaut, accompanies him to the clinic.

History of Present Illness (HPI):

The patient has had a 3-day history of fever that has gone as high as 101F. The pain worsens sometimes when he lies down. The boy says that the sharp pain is in the external canal of the right ear. The child also states that the pain worsens whenever he bends. However, he gets occasional relief by taking over-the-counter drugs. The patient has not had any diarrhea or vomiting, but has had symptoms of catarrh. He does not cough.

Review of Systems

The patient remains alert while sitting on his fathers lap. He appears not only well nourished but also hydrated. His neck is flexible and exhibits good range. The lymph nodes on the right side of his ears appear shotty. The nodes are neither tender nor show erythema. His breath sound is bilateral and seems clear to ausculation. The patients rib cage is rising and falling without retracting. When cardiovascular examination is conducted for the patients regular heart rate and sinus rhythm (RRR), the outcome does not reveal rubs, gallops or murmurs. However, his abdomen appears flat, soft, and it is not tender to palpation. Moreover, bowel sounds can be heard from all of the boys four quadrants. During this examination, hepatosplenomegaly has not been detected. HEENT examination indicates that the childs head is normocephalic and atraumatic. His pupils are round, equal and can sense accommodation and light. The examination cannot reveal ocular discharge. External ear examination reveals normal pinnae. When the external ear is touched, it does not feel tender. Otoscopic examination shows that his tympanic membrane is gray when in normal position. However, it has light reflexes. Bony landmarks can be observed, there is no fluid behind his tympanic membrane. Notably, the right tympanic membrane is erythematous and bulging. Purulent fluid can be seen behind the tympanic membrane. Further examination reveals that the tympanic membrane is opaque and without light reflex on the patients bony landmarks. The two nostrils have neither discharge, nor nasal flaring. Likewise, the mucous membranes are moist, and his 20 teeth are all intact without possible signs of caries. There are no lesions on his oral cavity.

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Past History:

Past Medical History:

The childs past medical history was found to be insignificant apart from hospitalization for neonatal sepsis at one week of age. The information from the last visit to the patients care provider shows nothing beyond the normal limits.

Patient Surgery History: Larrys surgery history is not provided. The father says that the patient has never undergone surgery in his life.

Patient Allergy History: Larry is said to be allergic to antibiotic penicillin. This drug causes itching and rashes on his body. Furthermore, the drug causes his tongue to swell.

Current Medications: The drug that the patient takes currently is Tylenol for relief of ear pain and fever.

Immunizations: To date, the child has received all the immunizations that were recommended for him.

Dietary History: Larry gets a balanced diet, but there are occasions when he takes egg whites, wheat products, peanuts and soya. The patient ate peanuts the last time he was flying to Texas to visit members of his extended family.

Family History

Family History: The boy lives with both of his parents. The mother is a 36 years old hairdresser while the father is a 41 years motor vehicle mechanic. The child has a nine year old brother who was also born normally. He got all the immunizations and has never suffered from serious illnesses. The family of this patient does not have a remarkable medical history.

Social History for alcohol, drug and tobacco use:

Larry is a Latino who lives with his parents at home. He is constantly fed with wheat products to make him stronger. The patients culture dictates that children have to be fed with soya products because they are considered healthy. They also believe in keeping cats as pets at home. Both parents are engaged in some income generating activities. The father has smoked for the past six years, consuming a packet of cigarettes each day. The mother is not a smoker and both parents deny taking hard drugs. The boy is only allowed to walk around their home compound while playing with his parents.

Level of History:


Objective Data

Vital Signs:

Oxygen Saturation:

Ht: Not applicable

Wt: Not applicable

BMI: Not Applicable

General Appearance:

Otoscopic examination shows that his tympanic membrane is gray and remains in its normal position. Further physical examination reveals bony landmarks on his tympanic membrane, but there is no fluid. His right tympanic membrane is erythematous with visible fluid.

Heart Examination: Not applicable in this case

Resp: His breath sounds are bilateral and equal. The sounds are also clear to auscultation. Physical examination has not identified retractions.

Ears: Tympanic membrane is gray, right tympanic membrane is erythematous with visible fluid.

Level of physical objective exam


Summary of Subjective and Objective Data

The patient presents with high fever and sharp pain in the external canal of the right ear that worsens whenever he bends. The boy also says that he has slight runny nose. In addition, there are lymph nodes on the right side of his ears. Further examination reveals purulent fluid behind the tympanic membrane. The patient is allergic to antibiotics and the father is a smoker. These conditions predispose the child to otitis media. Moreover, the child has been feeding on egg whites, wheat products, peanuts and soya, which increase the risk of contracting the disease. Otoscopic examination reveals that the patients tympanic membrane is gray. Additionally, there are bony landmarks on his ears. Most significantly, the right tympanic membrane has visible fluids. Objective data is significant during differential and main diagnosis.


Main Diagnosis/Problem:

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The child is suffering from otitis media. This occurs when the ear drum has a tear or is perforated. Similarly, it occurs when the eardrum experiences retraction that leads to the sucking of the middle ear space. Some of the sign of otitis media include fever, irritability, vomiting and diarrhea (Harmes et al., 2013). It is recorded that administering antibiotics cannot help in resolving otitis media.

There are signs and predisposing factors that have lead to the conclusion that the child is suffering from this condition. The patient in this case has a fever that, when measured, is found to be 101 F. The boy has been exposed to factors that can cause the condition. First, cigarette smoking can predispose a child to the condition, because the Eustachian tube is likely to be blocked whenever people are exposed to smoke (Ilechukwu et al., 2014). Second, the patient has been exposed to foods such as peanuts, wheat, soya, and egg whites, which are predisposing factors, too. Otitis media patients can be allergic to food and drugs. In this case, the patient is allergic to penicillin, which causes itching and rashes to his body.

Additional Health Problem:

The patient has not presented with symptoms of additional health problems during the conducted physical examinations.

Differential Diagnoses:

Acute Sinusitis

This disease occurs following inflammation of paranasal sinuses. It can last for one month or longer. Inflammation of the nasal airway often accompanies this condition, but it is preceded by rhinitis. Some of the symptoms of this condition include nasal stiffness, malaise, postnasal drip, and facial fullness. At other times, this condition can occur because of edema of the sinus tissues. It is appropriate to conclude that the patient is not suffering from this disease since he has not had symptoms of airway inflammation. Moreover, the medical assessment does not reveal malaise, nasal stiffness or facial fullness.


This disease occurs in cases of insect bites or ear piercings. Cellulitis can also occur after a trauma. People suffering from this condition experience a sudden onset and rapid development of pain. Likewise, such patients can exhibit redness, induration, tenderness or swelling of the ear auricle. At other times, the auricle may swell and protrude outwards. The patient in the present case is not suffering from this condition because the examination has not revealed redness of auricles or tenderness of the ear drum.

Risk Factors

One of the risk factors is the fathers cigarette smoking. The smoke has likely clogged the childs Eustachian tube (Ilechukwu et al., 2014).

The other risk factor is the exposure of the boy to allergens. For instance, he used to take penicillin, an over-the-counter antibiotic for pain relief, but ended up with an itch. In addition, Larry has been eating foods that cause allergy in children such as wheat, peanut and egg whites. It is important to remember that otitis media has a close association with allergy (Ilechukwu et al., 2014).

Keeping pets at home is a risk factor. Therefore, the cat that the family keeps in their home can predispose the child to the disease.

The last risk factor for this patient is boarding planes when he is going to visit relatives who live in other states, such as Texas. This increases his oxygen saturation level.

Pharmacologic Management

Drug Prescriptions, route, duration and amount prescribed:

Larry is taking Tylenol that is prescribed for ear pain and fever. After this examination, drug prescription will be based on how severe the symptoms of the patient are. In most cases, prophylactic antibiotics have been used to treat otitis media. The administered antibiotics need to target microorganisms such as Moraxella catarrhalis, Streptococcus pneumonia, and Haemophilus influenza. Antibiotics are administered when pain becomes severe, for example, in the current case. In addition, administration of antibiotics follows high fever. Tylenol inhibits cyclooxygenase, thus preventing conversion of arachidonic acid to prostaglandin H2 that is converted into inflammatory compounds. Importantly, inhibition of cyclooxygenase lowers the concentration of prostaglandin E2 and hypothalamic point for appropriate fever (Harmes et al., 2013).

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One of the drugs prescribed to this patient is Amoxicillin which is bactericidal for susceptible bacteria particularly during the multiplication phase. This drug should be taken for a maximum of ten days. The recommended dosage is 45 mg per 2.2 pound of the patients body weight. The drug is taken orally after 8 hours, and is divided into three daily doses.

The patient can also take Augmentin, particularly in this case, where the symptoms have become severe. This drug can be taken as oral suspension or tablets 3 times a day with a dosage of 40 mg.

The final drug that should be considered is Bactrim. The drug minimizes the ability of bacteria to use folic acid. Basically, it disrupts dihydrofolic acid production. This drug is considered safe for children. The recommended dosage is 8mg per kilogram of trimethoprim with 40 mg per kilogram of sulfamethoxazole taken after 12 hours for a period of 12 days (Harmes et al., 2013).

Diagnostic Testing

Referring the patient to a specialized physician will be required in order to use pneumatic otoscope to examine the boys ears to make conclusion regarding the amount of fluid that is behind the patients eardrum.

For the purpose of health education, the father will be advised to ensure that the child washes his hands thoroughly and frequently to reduce the chances of bacterial infection (Coco et al., 2010).

The parent should be told that it is unethical to expose the child to cigarette smoke because it worsens the situations. Therefore, the father must learn not to smoke near the young boy.

The parents should make sure that the child does not fly again until his condition has resolved (Coco et al., 2010).

The parents will be encouraged to refer the patient to a specialized doctor if there are 3 or more infections in a period of six months. The parents will also be urged to consult with a nurse practitioner should the boys condition worsen after a period 24-48 hours (Lieberthal et al., 2013).

Follow Up Plan

A nurse practitioner will make a follow up after 48 hours if the patients condition fails to improve or deteriorates further (Lieberthal et al., 2013).

A nurse practitioner will make a follow up 14 days after the initial prescription to advise whether there is a need to change medication.

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