1
Primary Care SOAP Note 1
Student Name: Michael Frank
Date: 4/20/22
Course: NUR695 A/B
Patient Initials: K C Age: 53
Gender: Female Ethnicity: African American
Chief Complaint: “I have a Cough that is accompanied by earache, itching, and a sensation of
fullness in the ear canal.”
History of Present illness: K.C. is a 53-year-old African-American female who, according to
her, is suffering from a cough and earache. These symptoms started to manifest themselves
around a week ago. The coughing fits are light in strength and occur on an irregular basis. It is
ineffective and is followed by a clear nasal discharge. For about two days, she has been running
a low grade temperature of around 100.1 degrees Fahrenheit or less. She rated her pain at 3 out
of 10 and it seems to intensify when she lies down and is eased with administration of Tylenol.
Additionally, putting pressure to the outside of her ears while she is laying down seems to
provide some relaxation for her.
Past Childhood Illnesses: She had asthma when she was 3 years was treated and recovered
fully.
PMH: No recent hospitalizations
Neither a medical issue nor an operative one
Her menstrual cycle began when she was 14 years old and ended on January 20th, 2021.
The most recent eye and dental examination was in September of 2021, and both were complete.
The last time she saw a doctor was in January of 2022.
PSH: None
2
Allergies: NKDA
Untoward Medication Reactions: There has been no documented intolerance in this patient.
Immunization Status: Up-to-date Immunizations
Screenings: TB screening was normal
FMH: Both of the patient's parents are still living. Her mother is 75 years old and in excellent
health, while her father is 78 years old and has effectively controlled hypertension, according to
the family. She has two children, a 12-year-old daughter and a son who is nearly 18 years old,
and neither of them has any medical issues. Her maternal grandmother and grandpa died away
some years ago, at the ages of 70 and 67, respectively. She, on the other hand, is completely
oblivious of the circumstances behind their deaths. In addition, her paternal grandpa and
grandmother passed away many years ago, at the ages of 60 and 64, respectively. She maintains
she didn't know them very well, and as a result, she doesn't even know what caused their deaths.
Personal History/Social History:
K. C. is married and works as a high school English teacher at the moment. Conditions at her
home she lives in a single house with her children and her spouse. Her sleeping habits- She
attempts to obtain at least 7 hours of sleep every day, but she does not do so on a consistent
basis. The patient does not smoke, drink, or engage in any other illicit drug or substance misuse
behavior. Her religious affiliation is Christian, and her diet is almost balanced.
Females: OB/GYN: None
Sexual History: Active
3
Current Medications/OTCs/Supplements: Tylenol 650 mg once every 6 hours.
Review of Systems:
General: Nine-year-old African American girl is the patient she’s attentive, receptive, and willing
to work with you. Low-grade fever, but no chills or malaise from her mother. The lack of sleep
she has been experiencing hasn't resulted in any weight reduction or growth.
Skin: N/A
HEENT:
Head: Denies headache
Eyes: No watering or matting in the eyes
Ears: No hearing problems
Nose: Denies that a runny nose, visible nasal discharge.
Throat: Ear pain, but denies any drainage.
Breasts: No discharge, or wrinkling, no dimpling, or discoloration of the skin.
Respiratory: Coughing is ineffective. Dyspnea during exercise is denied, as is breathing trouble.
Cardiovascular: There is no evidence of chest discomfort, no SOB, and no history of palpitations
or murmurs. There is no edema or swelling in the extremities. The presence of pain, numbness,
and tingling is denied.
Gastrointestinal: K. C. did experience one episode of vomiting but none since. No diarrhea or
constipation reported
Genitourinary: No smelly discharge. Skin is uniform with no signs of inflammation pimples. No
signs of tenderness or lumps around the genital area.
Peripheral Vascular: Not assessed
4
Musculoskeletal: No soreness or discomfort in the joints and can move over its whole range.
Neurologic: The patient had no history of fainting and denies weakness or loss of coordination,
or headaches and dizziness, or vision changes.
Hematologic: There is no evidence that anemia, bruises, or wounds present.
Endocrine: Her tolerable to heat and cold is normal, with no weight changes. He also denies
polydipsia, hair changes, or polyuria.
Psychiatric: Denies mood swings, anxiety, difficulties in concentration, and depression
Screening Tool: PHQ-2 Depression Scale CRAFFT done, came back negative.
Physical Exam:
Vital Signs:
B/P: 120/80
T: 99.9
RR: 15
Ht: 5’3 ft
Wt: 176 pounds
General: K.C. is kind and looks to be in good health. She may be seen walking about in a neat,
clean outfit with no foul odor. There's no sign of discomfort.
Skin: No rash, eczema, or pimples on the skin. The patient expresses no itching.
HEENT:
Head: norm cephalic with no palpable masses depressions
Eyes: The conjunctiva are free of blemishes. There was no evidence of drainage. The sclera is
transparent, and the pupils are equal, circular, and light receptive.
5
Ears: Hearing is in good working order. The tympanic membrane is swollen, erythematous, and
bulging in both directions. Both ears are filled with fluid.
Nose: The turbinate's are covered in a thick layer of mucus. Neither congestion nor erythema
may be seen. There was no septal deviation observed. There are no signs of infection in the
mucous membranes.
Throat: There is no erythema or edema of the tonsil pillars, and the throat is clean.
Neck: Denies masses in the neck region, stiffness, or swollen lymph nodes. Thyroid gland is
normal, nontender, without tumors or goiters.
Breasts: No tenderness or pain.
Lungs: The sounds of breathing are distinct. Breathing is unlabored on both sides, and chest
discomfort is denied.
Heart: Heart has a RRR, no murmurs or gallops, no edema, pulses palpable and strong, capillary
refill less than three seconds.
Abdomen: There has been no diarrhea or constipation reported.
Genitourinary: There is no odiferous odor. Pimples and inflammation are not visible on the skin.
The vaginal region is neither painful nor lumpy.
Rectal: Not assessed
Peripheral Vascular: Not assessed
Extremities: Musculoskeletal: Not assessed
Neurological: CNI-Normal Sensation of Smell
CNII-Visual Acuity in the Normal Range.
CN III, IV, VI- The patient's eyelids open in a consistent manner on both sides.
CN V-normal corneal reflex, facial sensibility, opening of the jaw, and biting strength
6
CN VII- Normal brow lift and eyelid closure on both sides. Capable of smiling with standard test
buds.
CN VIII- Rinne and Weber's tests reveal proper conduction of air and bone.
Normal gag reflex, palate elevation, and phonation in CN IX, X
CN XI- Lateral head rotation, neck flexion, and shrugging of the shoulders
CN XII- Normal tongue protrusion and strength of lateral deviation
.
Differential Diagnosis Diagnostic Reasoning Exercise:
Differential
Pathophysiology
Diagnoses
(include APA
Pertinent Positives
Pertinent Negatives
We chose otitis
Mastoiditis, a
citations)
Otitis media
When inflammation
(Browning et al,
and moisture build up media because it is a
potentially life-
2018)
in the middle ear, it
frequent ear infection
threatening
can be quite painful.
with symptoms like
consequence of otitis
discomfort in the ear,
media, causes
ear tugging, fever,
soreness, swelling,
drainage, headache,
and erythema in the
and loss of hearing as
mastoids as well as
well as changes in
external ear
appetite and balance.
proptosis.
7
Cholesteatoma media
It is an ear tumor that
Hearing loss and
Hearing loss or
grows in the ear
painless ottorrhea are
inability to improve
canal.
both possible
hearing are the most
symptoms of
common risks.
cholesteatoma. They
are susceptible to
infection and can
produce redness and
drainage in the
eardrum. Eardrum
opacification is also
prevalent (Tipton et
al, 2019).
Bullous Myringitis
Middle ear infections
Fever, Neck stiffness
A common symptom
are caused by the
and discomfort that
of bullous is
same virus or
makes it difficult to
temporary hearing
bacteria. Among
chew or move,
loss, but if left
youngsters,
Blisters and
untreated, the damage
Myringitis is the most inflammation in the
to the ear can be
common cause of the
ear are causing a lot
irreversible.
common cold.
of agony. Exudation
from the ear.
8
(Kasinathan &
Kondamudi, 2021).
Mastoiditis (Berry,
Middle-ear infection
common mastoiditis
Hearing loss, blood
2019).
caused this. From the
symptoms include
clots, meningitis or a
ear down to the
fever, headache,
brain abscess are all
mastoid bone, the
redness in and behind
possible side effects
infection spreads.
the ears as well as ear
of mastoid infection.
swelling, and
However, these
discharge from an
consequences may
infected mastoid,
usually be avoided
and you can fully
recover with early
and adequate
antibiotic therapy and
drainage.
Assessment/Plan:
Otitis media: Otitis media can usually be diagnose based on symptoms and physical
examination using an otoscope. An otoscope was used to visualize the ears, throat, and nasal
passage. The patient tympanic membrane was erythematic, inflamed, with fluids behind the
tympanic membrane. Other instruments used in the diagnosis of otitis media are the pneumatic
otoscope which allows the health care professional to visualize the ear and determine if fluid is
present behind the eardrum using air (Berry, 2019). If fluid is present when a puff of air is
9
administered there should be no movement of the eardrum (Mayo Clinic, n.d.). Laboratory
evaluations is not usually necessary for patients with otitis media, but a sepsis work up is
necessary if the fever continues to increase. Pain assessment and control should be part of otitis
media pharmacologic treatments. I would prescribe Tylenol or ibuprofen to ease the patient's
discomfort. A common treatment for ear infections is amoxicillin. The patient was given
Amoxicillin/clavulanate 875 mg bid for 10 days, with a follow up appointment in two weeks.
Patient was instructed to go to the ER if her symptoms worsen in 48-72 hours.
Referrals: If ear infections become persistent with fluid accumulation a referral will be made to
an audiologist/speech.
Cholesteatoma media: Even though surgery is seldom necessary, if a cholesteatoma is
discovered, it must be surgically removed. The eardrum is repaired by tympanoplasty after a
mastoidectomy, which removes the diseased tissue from the bone (Tipton et al., 2019). A
patient's stage of sickness determines the sort of surgery they need.
Education: Making the patient aware of the possibility of congenital cholesteatomas so that they
can be treated as soon as they are discovered. Ear infections can be prevented by treating them as
soon as possible and thoroughly. Even so, cysts may still form.
Referrals: Depending on the difficulties, this may or may not happen.
Bullous Myringitis: Since inflammation of the ear drum caused by bullous myringitis and in
most cases, it is triggered by a head cold that causes acute ear discomfort, loss of hearing, and
fever. I will check for drum blisters. For the treatment of bullous myringitis, the difference is
that pain control may need a more aggressive therapy. For this reason, they are more likely to
10
return, as well as more likely to be infected with germs. There are several reasons why first-line
treatment in BM is systemic antibiotics and rigorous outpatient monitoring (Kasinathan &
Kondamudi, 2021).
Education: The lips, nose and eyes should be kept clean and free of any contact. Make sure to
wash your hands often during the day to avoid spreading germs.
Referrals: No referrals.
11
References
Berry, W. S. (2019). Otitis, Sinusitis, and Mastoiditis. In Introduction to Clinical Infectious
Diseases (pp. 37-51). Springer, Cham.
Browning, G. G., Weir, J., Kelly, G., & Swan, I. R. (2018). Chronic otitis media. In ScottBrown’s Otorhinolaryngology Head and Neck Surgery (pp. 977-1019). CRC Press.
Kasinathan, S., & Kondamudi, N. P. (2021). Bullous Myringitis. In StatPearls [Internet].
StatPearls Publishing.
Mayo Clinic. (2016). Ear Infection Middle Ear. Retrieved from
http://www.mayoclinic.org/diseases-conditions/earinfections/diagnosistreatment/diagnosis/dxc-20199896
Tipton, C. B., Honsinger, K. L., Harris, M. S., & Malhotra, P. S. (2019). Acute Otologic
Infections in Pediatric Patients. Journal of Pediatric Infectious Diseases, 14(02), 052062.