NURS 6541 Week 3 Assignment – acute otitis media SOAP Note
NURS 6541 Week 3 Assignment – acute otitis media SOAP Note
SOAP assignment
Subjective
A 4-year-old male patient’s mother stated that the child had complained of an earache. The child had only made it known to his mother after three days of discomfort. The patient says that a bug crawled into his right ear while playing in the park. The mother believes it is more of an ear infection as she has checked the patient’s ear but found no foreign objects. The patient says there are no fluttering sounds in his ear and neither is the ear blocked
Objective
Vital Signs: Ht 111cm. Wt 19.1kg, BP: 117.75, HR 84, RR 18, T 39C
General observation: no acute distress. The patient is well nourished
CV: no gallops or murmurs, RRR
MSK: full motion range in all body extremities
Abdomen: no hepatosplenomegaly, non-disteneded, non-tender, soft, bowel sounds in all four quadrants
Lungs: no wheezing, rales, rhinchi, CTAB.
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Neck: non-tender and mobile, no masses, supple, right cervical lymph node 1cm palpable
HEENT: pink conjunctiva, white sclera. Ears bilateral canals are clean, pearly grey left tympanic membrane with visible bony landmarks and light reflex. Bulging and erythematous right tympanic membrane with no bony landmarks visualized and with reduced light reflex. No observation of purulent drainage. Mastoid bone has no pain on palpitation NURS 6541 Week 3 Assignment – acute otitis media SOAP Note.
Assessment
The patient has acute otitis media
Comparisons were made of the left and right ear to help in elucidating any clinical findings that were abnormal. The assessment also ruled out the possibility of:
Otitis media with effusion- no collection of ear fluid was observed. The patient did not have an upper respiratory infection, sore throat, or cold (Williamson, 2015)
Cholesteotoma: no cyst observed. Patient does not have a history of ear infection. No hearing loss was reported (Prasad, Swapanthi & Harshitha, 2018)
Mastoiditis: no pus excreted from the ear. No swelling behind the ear. No difficulty in hearing reported. No throbbing reported (Stergiopoulou & Walsh, 2016).
Plan
Rx: Benzocaine 20% ear drops. Every 1-2 hours as needed for managing pain
160mg/5ml Tylenol every 4-6 hours as needed to manage fever or pain
90mg/kg/day Amoxicillin bid q10
Non-pharmacological treatment: Avoid inserting objects in the ear. Osteopathic Manipulative Treatment (OMT) is recommended. OMT has been shown to be effective when done in combination with pharmacological treatment (Steele, Carreiro, Viola, et al., 2014).
Amoxicillin is used as the first line of treatment (Nwokoye, Egwari, & Olubi, 2015). It is essential that pain is managed. Benzocain is used as additional pain management for children aged 2 years and above.
Patient Education: Improvement of symptoms should be observed within 24-48 hours following antibiotic therapy
Follow Up: The patient should return for a check-up if the condition does not improve after 48 hours following antibiotic administration.
Reflection Notes: The child first stated that an insect had invaded its ear. Children below 4 years are known to insert foreign objects in their ears while playing or out of simple curiosity or boredom. I should have asked the patient if there had been incidences when anything got stuck in his ear. Frequent jamming of foreign objects can cause recurrent ear infections. The parent should be asked to be more observant as the child plays. The child should not be allowed to play with small-enough objects that can easily jam in the ears. In a similar situation, I would ask the patient if he had ever inserted objects in his ears prior to the hospital visit.
References
Nwokoye, N. N., Egwari, L. O., & Olubi, O. O. (2015). Occurrence of otitis media in children and assessment of treatment options. The Journal of Laryngology & Otology, 129(8), 779-783.
Prasad, K. C., Swapanthi, M. B., & Harshitha, T. R. (2018). Aural Atresia with Cholesteotoma and Its Management Strategies. Indian Journal of Otolaryngology and Head & Neck Surgery, 70(4), 587-590.
Steele, K. M., Carreiro, J. E., Viola, J. H., Conte, J. A., & Ridpath, L. C. (2014). Effect of osteopathic manipulative treatment on middle ear effusion following acute otitis media in young children: a pilot study. The Journal of the American Osteopathic Association, 114(6), 436-447.
Stergiopoulou, T., & Walsh, T. J. (2016). Fusobacterium necrophorum otitis and mastoiditis in infants and young toddlers. European Journal of Clinical Microbiology & Infectious Diseases, 35(5), 735-740.
Williamson, I. (2015). Otitis media with effusion in children. BMJ clinical evidence, 2015.
Assignment 1: Practicum – SOAP Note
SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care. Please refer to this week’s Learning Resources for guidance on writing SOAP Notes.
Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What were your plans for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
In this case, we can do 4 years old boy with flu like symptoms, otitis media.
Name: NURS_6541_Week3_Assignment1_Rubric
Grid View
List View
Excellent
Good
Fair
Poor
Subjective: CC
(1 point)
Points:1 (1.00%)
Points Range:1 (1.00%) – 1 (1.00%)
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Subjective: Pertinent positives LOCATES
(10 points)
Points:10 (10.00%)
Points Range:9 (9.00%) – 10 (10.00%)
Includes thorough, accurate, and pertinent positives LOCATES
Points Range:8 (8.00%) – 8 (8.00%)
Includes accurate and pertinent positives LOCATES
Points Range:7 (7.00%) – 7 (7.00%)
Includes positives LOCATES
Points Range:0 (0.00%) – 6 (6.00%)
Does not include positives LOCATES or positives LOCATES are not pertinent
Subjective: Pertinent negatives (from ROS)
(10 points)
Points Range:9 (9.00%) – 10 (10.00%)
Includes thorough, accurate, and pertinent negatives (from ROS)
Points Range:8 (8.00%) – 8 (8.00%)
Includes accurate and pertinent negatives (from ROS)
Points Range:7 (7.00%) – 7 (7.00%)
Includes negatives (from ROS)
Points:0 (0.00%)
Points Range:0 (0.00%) – 6 (6.00%)
Does not include negatives (from ROS) or negatives (from ROS) are not pertinent
Subjective: Pertinent PMH, SH, and FH
(3 points)
Points:3 (3.00%)
Points Range:0 (0.00%) – 3 (3.00%)
Includes thorough, accurate, and pertinent PMH, SH, and FH
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:2 (2.00%) – 2 (2.00%)
Includes PMH, SH, and FH
Points Range:0 (0.00%) – 1 (1.00%)
Does not include PMH, SH, and FH or PMH, SH, and FH are not pertinent
Subjective: Medications and drug/food allergies are not included
(1 point)
Points:1 (1.00%)
Points Range:1 (1.00%) – 1 (1.00%)
Does not include medications and drug/food allergies
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Includes medications and drug/food allergies
Objective: VS including BMI
(2 points)
Points:2 (2.00%)
Points Range:2 (2.00%) – 2 (2.00%)
Includes VS including BMI
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
NURS 6541 Week 3 Assignment – acute otitis media SOAP Note
Points Range:0 (0.00%) – 1 (1.00%)
Does not include VS including BMI
Objective: Heart and lungs
(1 point)
Points:1 (1.00%)
Points Range:0 (0.00%) – 1 (1.00%)
Includes heart and lungs
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Does not include heart and lungs
Objective: Systems or specialty exam techniques that are not necessary to arrive at a diagnosis are included.
(5 points)
Points:5 (5.00%)
Points Range:5 (5.00%) – 5 (5.00%)
Includes thorough explanation of systems or specialty exam techniques that are not necessary to arrive at a diagnosis
Points Range:4 (4.00%) – 4 (4.00%)
Includes systems or specialty exam techniques that are not necessary to arrive at a diagnosis
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 3 (3.00%)
Does not include systems or specialty exam techniques that are not necessary to arrive at a diagnosis
Objective: Systems or specialty exam techniques that are necessary to arrive at your diagnosis are omitted.
(10 points)
Points:10 (10.00%)
Points Range:9 (9.00%) – 10 (10.00%)
Omits systems or specialty exam techniques that are necessary to arrive at your diagnosis
Points Range:8 (8.00%) – 8 (8.00%)
Omits most systems or specialty exam techniques that are necessary to arrive at your diagnosis
Points Range:7 (7.00%) – 7 (7.00%)
Omits some systems or specialty exam techniques that are necessary to arrive at your diagnosis
Points Range:0 (0.00%) – 6 (6.00%)
Does not omit systems or specialty exam techniques that are necessary to arrive at your diagnosis
NURS 6541 Week 3 Assignment – acute otitis media SOAP Note
Objective: Diagnostic test results
(2 points)
Points:2 (2.00%)
Points Range:2 (2.00%) – 2 (2.00%)
Includes diagnostic test results
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 1 (1.00%)
Does not include diagnostic test results
Assessment: Priority Diagnosis
(30 points – 10 points for each priority diagnosis. If less than 3 are appropriate to include – simply no other diagnoses to consider – you will receive all 30 points. Please do not “stretch” to find 3 if they are not actual possibilities.)
Points:30 (30.00%)
Points Range:27 (27.00%) – 30 (30.00%)
Includes three appropriate priority diagnoses
Points Range:24 (24.00%) – 26 (26.00%)
Includes three appropriate priority diagnoses but some are incorrect or missing
Points Range:22 (22.00%) – 23 (23.00%)
Includes fewer than three priority diagnoses but some are incorrect or missing
Points Range:0 (0.00%) – 21 (21.00%)
Does not include three appropriate diagnoses
Plan: Medications discontinued (“d/c lisinopril 10 mg daily”)
(1 point)
Points:1 (1.00%)
Points Range:1 (1.00%) – 1 (1.00%)
Includes discontinued medications
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Does not include discontinued medications
Plan: Medications started (“start Avapro 150 mg daily”)
(2 points)
Points:2 (2.00%)
Points Range:2 (2.00%) – 2 (2.00%)
Includes medications started
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 1 (1.00%)
Does not include medications started
Plan: Alternative therapies if appropriate (1 point)
Points:1 (1.00%)
Points Range:0 (0.00%) – 1 (1.00%)
Includes alternative therapies if appropriate
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Does not include alternative therapies if appropriate
Plan: Health Promotion strategies – patient/family education
(3 points)
Points:3 (3.00%)
Points Range:0 (0.00%) – 3 (3.00%)
Includes health promotion strategies – patient/family education
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:2 (2.00%) – 2 (2.00%)
Includes health promotion strategies – patient/family education, but may not be entirely appropriate for the patient/family
Points Range:0 (0.00%) – 1 (1.00%)
Does not include health promotion strategies – patient/family education
Plan: Disease Prevention strategies with timeframe if appropriate
(3 points)
Points:3 (3.00%)
Points Range:3 (3.00%) – 3 (3.00%)
Includes disease prevention strategies with timeframe if appropriate
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:2 (2.00%) – 2 (2.00%)
Includes disease prevention strategies, but does not include timeframe or disease prevention strategies are not appropriate
Points Range:0 (0.00%) – 1 (1.00%)
Does not include disease prevention strategies
Plan: Diagnostic tests ordered with timeframe (now, in 2 weeks, prior to f/u visit in 3 months)
(3 points)
Points:3 (3.00%)
Points Range:3 (3.00%) – 3 (3.00%)
Includes appropriate diagnostic tests ordered with timeframe
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:2 (2.00%) – 2 (2.00%)
Includes diagnostic tests but they may not be appropriate, or the timeframe is incorrect or not included
Points Range:0 (0.00%) – 1 (1.00%)
Does not include diagnostic tests
NURS 6541 Week 3 Assignment – acute otitis media SOAP Note
Plan: Referrals or consultations if appropriate
(1 point)
Points:1 (1.00%)
Points Range:1 (1.00%) – 1 (1.00%)
Includes referrals or consultations if appropriate
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Does not include referrals or consultations if appropriate
Plan: Follow-up interval
(1 point)
Points:1 (1.00%)
Points Range:1 (1.00%) – 1 (1.00%)
Includes follow-up interval
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
NA
Points Range:0 (0.00%) – 0 (0.00%)
Does not include follow-up interval
Reflection Notes: What did you learn from this experience? Any ah-ha’s?
(10 points)
Points:10 (10.00%)
Points Range:0 (0.00%) – 10 (10.00%)
Response includes thoughtful and insightful explanation of significant learnings
Points Range:8 (8.00%) – 8 (8.00%)
Response includes thoughtful and insightful explanation of learnings
Points Range:7 (7.00%) – 7 (7.00%)
Response includes explanation of learnings
Points Range:0 (0.00%) – 6 (6.00%)
Response does not include explanation of learnings
Raw Total: 90.00 (of 100)
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