Peds OM Visit

SOAP Note Peds OM Visit Chief Complaint: Patient’s mother states that she “thinks he has an ear infection.” History of Present Illness: J.S. is a 20 month old healthy appearing Hispanice male who presented to the clinic for a possible ear infection. He resides with his grandparents, mom, and big sister. Per the patient’s mother, he has been pulling at his left ear and running a low grade temperature (99.6F-100F) for around 2 days. The patient has been very irritable and somewhat fussy as well. She said that she gives him liquid Tylenol in order to help with the pain and break his fever, with this working for around 6 hours before she has to give him more. Developmental Growth As per mom, he recognizes names of familiar people, objects, and body parts, he follows simple instructions, he like to scribbles in a paper sheet and kicks a balls. During the interview, he walks alone, climbs onto and down from furniture unassisted, he was able to points to object or picture when it’s named for him, stands on tiptoe and Uses two- to four-word sentences Past Medical History: J.S. has had no major illness to date. She has no history of major problems. Her history does include: Immunizations up to date for age: o Hep B series o DTaP: 1st, 2nd, and 3rd dose o IPV: 1st, 2nd, and 3rd o MMR: 1st dose o VAR: 1st dose o Hep A series Surgical History: Denies surgical history per mom Allergies: No Known Allergies Medications: None Family History: Mother, 31yo - HTN Father, 31yo – asthma Sister, 6yo - asthma Grandfather, deceased 72 yo - MI Grandmother, 82 yo – cataracts, HTN Social History: Resides in a 2nd floor apartment with her boyfriend and daughter, mother reports a good support system. Mom smokes cigarettes in the home and socially drinks alcohol; denies illegal drug use. J.S. attends daycare Monday through Friday. Sits in a 5-point harness car seat with latch system Review of Systems: General: Irritable and crying more than usual, low grade temp; denies weight loss, fever, night sweats, fatigue, and chills HEENT: Guarding and pulling at left ear, teething; Denies difficulty hearing, runny nose, mouth sores, and sore throat RESP: Denies cough, sputum, wheezing, and dyspnea CV: Denies cyanosis, swelling, erythema of skin GI: Denies constipation, abdominal pain, nausea, vomiting and diarrhea GU: Currently potty training during the day and diapers at bedtime; denies difficulty urinating MS: Denies recent trauma and falls SKIN: Denies rash, lesion, or color changes NEURO: Denies difficulty speaking and loss of consciousness PSYCH: Denies difficulty sleeping, behavioral changes, concerns for growth/development, and hyperactivity Physical Exam: Vitals: T 101.2F (38.4C) oral | Pulse 110, regular| Resp 30 | BP 98/65 | Wt 28lbs (12.7 kg) | Ht: 33.2in | SpO2 98% | BMI 18.1 kg/m2 GENERAL: Sitting on mom’s lap, was seen walking in room upon my entrance. Appears to be irritable and cries intermittently. Patient noted to be guarding his left ear HEAD: Normocephalic, fontanels are closed, suture lines intact, hair evenly distributed EYES: PERRLA, sclera white, conjunctiva pink, extra ocular movements intact; no hemorrhage or exudate noted EARS: External appearance normal-no lesions, redness, or swelling; on otoscopic exam tympanic membranes and inner ear are red, fluid is also noted behind the tympanic membrane. Hearing is intact. NOSE: Nares patent bilaterally, septum midline, normal pink mucosa, no polyps, no discharge NECK: Neck symmetrical, supple, full ROM, non-tender without masses THROAT/MOUTH: Oral mucosa pink and moist; teething w/ 8 teeth noted; pharynx w/o erythema, exudates, or lesions. LUNGS: Even and unlabored, bilaterally clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds CV: Regular rate and rhythm, normal sinus rhythm with S1, S2 normal; no murmur, clicks, rubs, or gallop GI: Positive bowel sounds in all four quadrants. Soft, non-distended, non-tender; no guarding, rebound, or masses noted GU: No bladder distention. Two testes palpated. No redness or diaper rash noted. SKIN: Warm, dry, and intact, capillary refill < 3sec.; no rash, lesion, pallor or cyanosis noted MS: Full range of motion in all four extremities, grossly normal function and strength of extremities. No bone, joint, or muscle tenderness or swelling. NEURO: Speech clear. Posture erect. Balance stable; gait normal. Symmetric movements, reflexes grossly intact, no focal deficits. PSYCH: Mood and affect appropriate. Irritable during exam and comforted by mom. Growth Chart/Developmental Assessment Tool: Completed on last visit an 18-month ASQ: Results: Development is on schedule; no further action taken at this time Lab Data/Tests: (last visit at 18 months) H/H - 11.4/34.3 (9.9-17.3)/(29-44) Lead - <1.9 (0-5) Differential Diagnosis: 1. Otitis Media Mother reports that patient has been pulling at his left ear and crying more than usual, which is a sign of pain in a pediatric patient. He has also been running a low-grade fever. Upon assessment, the ear canal and tympanic membrane are both red, with fluid noted behind the tympanic membrane. 2. URI Patient is having ear pain and there is fluid noted behind the patient’s ear. Also has low grade temp. This could be an early sign of a URI. Refuting data: There are no respiratory symptoms, such as coughing noted. 3. Sinusitis Patient has fluid behind the ear and redness noted in the ear canal. Also has low grade temp. Refuting data: Patient does not have nasal drainage, signs or a red or sore throat or sinus tenderness. 4. Otitis Externa Patient is pulling his left ear lobe and according to the patient’s mother he has been much more irritable lately. Refuting data: The ear is red and inflamed into the canal. There is also fluid noted behind the tympanic membrane. Definitive Diagnosis: Otitis Media Therapeutic Plan: 1. Amoxicillin 7ml BID for 10 days Calculation: Usual dosage: 90mg/kg/day in divided doses every 12 hours 90mg (12.7kg) = 1,143 mg/day 1143/2= 571.5 mg/dose Drug Concentration: 400mg/5mL 571.5mg/400mg= 1.4x5mL= 7mL 2. Children’s Tylenol for pain and/or fever 3. Follow-up: Two weeks or earlier if symptoms worsen. This will give the child time to have completed the full cycle of antibiotics. 4. Reviewed anticipatory guidance based upon the Bright Futures Guidelines developed by The American Association of Pediatrics (AAP) Health Promotion: Most of the injuries to children under 2 years occurred in the home. According to the Center for Disease Control and Prevention (CDC) (2019), children 1 to 4 years of age had the highest rates of nonfatal falls and poisoning. Injury prevention and safety recommendations in regards to childproofing the home include keeping medications and cleaning supplies out of reach, guarding the stairs and outlets, and keeping children away from heavy/hot objects (Schnitzer, 2006). Health Education: The child should not be exposed to cigarette smoke as this triggers the allergic reaction blocking the eustachian tube. He should also be kept far from dust and other particles. Csákányi et al. suggests that second-hand smoke increases recurrent episodes of acute otitis media (AOM). Smoking cessation of family members who are often around the child is very important. Secondhand smoke exposure may also cause acute lower respiratory infections such as bronchitis and pneumonia in infants and young children. References CDC Childhood Injury Report. (2019, February 06). Retrieved from https://www.cdc.gov/safechild/child_injury_data.html Csákányi, Z., Czinner, A., Spangler, J., Rogers, T., & Katona, G. (2012). Relationship of environmental tobacco smoke to otitis media (OM) in children. International journal of pediatric otorhinolaryngology, 76(7), 989–993. https://doi.org/10.1016/j.ijporl.2012.03.017 Schnitzer, P. G. (2006, December 01). Prevention of Unintentional Childhood Injuries. Retrieved from https://www.aafp.org/afp/2006/1201/p1864.html