SOAP Note: Acute Otitis Media

Subjective

• Chief Complaint: Fever and right ear pain.
• History of Present Illness (HPI): A 3-year-old female presents with a 3-day history of cold symptoms, including nasal congestion and sniffles. The mother reports that the child started complaining of right ear pain and has a fever of 37.8°C (100°F). The child has been irritable and crying frequently. No nausea, vomiting, diarrhea, headache, or changes in urine output.
• Past Medical History (PMH): No significant medical history reported.
• Family History (FH): Non-contributory.
• Social History (SH): Lives at home with parents; no recent travel or sick contacts reported. Attends daycare.
• Medications: None reported.
• Allergies: No known drug or food allergies.

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Objective

• Vitals: Temperature: 37.8°C (100°F), Pulse: 110 bpm, Respiratory Rate: 20 breaths/min, BP: Normal for age.
• General Appearance: Irritable, crying, mildly cooperative during the examination.
• HEENT:
  • Head: Normocephalic, atraumatic.
  • Eyes: PERRLA, no conjunctival injection.
  • Ears: Right tympanic membrane is erythematous and bulging with limited mobility on pneumatic otoscopy. Left tympanic membrane is normal.
  • Nose: Thick green nasal discharge present.
  • Throat: Mildly erythematous, no exudate.
• Neck: No lymphadenopathy.
• Respiratory: Clear to auscultation bilaterally, no wheezing or rales.
• Cardiovascular: Regular rate and rhythm, no murmurs.
• Abdomen: Soft, non-tender, no organomegaly.
• Skin: No rashes or lesions.

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Assessment
Primary Diagnosis: Acute Otitis Media (AOM)

• ICD-10 Code: H66.90 (Otitis media, unspecified, without spontaneous rupture of ear drum)

Rationale:
The patient presents with classic symptoms of AOM, including ear pain, fever, and findings of a bulging, erythematous tympanic membrane with reduced mobility on otoscopy. The presence of recent upper respiratory symptoms supports the diagnosis as AOM often follows a viral upper respiratory infection.

Differential Diagnoses:

1. Viral Upper Respiratory Infection (URI) – Concurrent but not the primary diagnosis.
2. Otitis Externa – Unlikely due to the absence of ear canal tenderness or discharge.
3. Sinusitis – Unlikely in a 3-year-old due to incomplete sinus development.

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Plan

1. Diagnostics:
   • Diagnosis based on clinical findings; no imaging or lab tests necessary.
2. Medications:
   • Amoxicillin 80-90 mg/kg/day divided into two doses for 10 days.
   • Acetaminophen for pain and fever management (15 mg/kg/dose every 4-6 hours as needed).
3. Patient Education:
   • Educate the mother on proper administration of medications.
   • Discuss signs of complications such as persistent fever, worsening symptoms, or ear discharge.
   • Encourage hydration and rest.
4. Follow-Up:
   • Reevaluate in 48-72 hours if symptoms do not improve or worsen.
   • Routine follow-up in 2 weeks to assess for resolution.
5. Referral:
   • None needed unless symptoms persist or complications arise, in which case referral to an ENT specialist may be considered.

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Evaluation & Management Score Sheet

• History: Comprehensive
• Exam: Detailed
• Medical Decision Making: Moderate complexity

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References

• American Academy of Pediatrics. (2019). The diagnosis and management of acute otitis media. Pediatrics, 131(3), e964-e999. https://doi.org/10.1542/peds.2019-0288
• Rosenfeld, R. M., Shin, J. J., Schwartz, S. R., et al. (2019). Clinical practice guideline: Otitis media with effusion. Otolaryngology–Head and Neck Surgery, 154(1_suppl), S1-S41. https://doi.org/10.1177/0194599818809761

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