Pediatric SOAP NOTE

S: 6-year-old Caucasian male presents to the clinic his father with a complaint of earache and decreased hearing to bilateral ears.
O: BP: 96/58, Respiration: 24, Pulse Ox: 96 % RA, Temperature: 97.6 °F, Height: 118.7cm, Weight: 52 lbs 11.2oz, BMI: 16.95
A: Redness and swelling noted to bilateral ears. No fever or chills reported. Audiometric testing was completed using insert earphones.
P: Amoxicillin ear drops 3- 4 times a day for 1 week. Follow up in 3 days if symptoms gets worse or does not improve.

Primary diagnosis:
Acute otitis media (AOM)

Differential diagnosis:
• Mastoiditis
• Otitis externa
• Labyrinthitis.

For each diagnosis, provide supportive documentation with evidence based guidelines. Support your selection with rationales keeping in mind the likelihood of each subsequent diagnosis based on the patient’s age, gender, and race, risk factors, lifestyle choices, and co-morbidities. For each diagnosis, provide supportive documentation with evidence-based guidelines. Also, tell us why you choose the primary diagnosis and differential diagnosis. Why are you ruling out the differential diagnosis out and selecting the primary diagnosis?

Sample Solution