soap note for acute otitis media

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03-02-2025

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SOAP Note for Acute Otitis Media (AOM)

Patient: [Patient Name], [Age], [Sex]

Date: October 26, 2023

Subjective:

• Chief Complaint (CC): Right ear pain, fever, and decreased hearing for 2 days.
• History of Present Illness (HPI): The patient presents with a two-day history of right ear pain described as sharp and throbbing. The pain is worse at night and is not relieved by over-the-counter analgesics. The patient reports a fever of 101°F (38.3°C) this morning, which has subsided slightly. He/She also complains of a decreased ability to hear out of the right ear. Denies any recent upper respiratory infection or trauma to the ear. No history of ear tubes or prior AOM episodes.
• Past Medical History (PMH): No significant past medical history. No known allergies.
• Medications: None.
• Allergies: None known.
• Social History (SH): Lives at home with parents. Attends preschool. No known exposure to cigarette smoke.
• Review of Systems (ROS):
  • General: Fever (101°F this morning, now 99.8°F), fatigue.
  • ENT: Right ear pain, decreased hearing in right ear, no nasal congestion or drainage.
  • Respiratory: No cough or shortness of breath.

Objective:

• Vital Signs: Temperature: 99.8°F (37.7°C), Heart Rate: 90 bpm, Respiratory Rate: 20 breaths/min, Blood Pressure: 96/60 mmHg.
• Otoscopic Exam: Right tympanic membrane is erythematous and bulging with decreased mobility. Left tympanic membrane appears normal.
• Hearing Assessment: Right ear hearing appears diminished compared to the left, per patient report and observation. Formal audiometry not performed.

Assessment:

• Diagnosis: Acute Otitis Media (AOM), right ear.

Plan:

• Treatment: Amoxicillin 80mg/kg/day divided BID for 10 days. Acetaminophen for fever and pain as needed. Follow-up appointment in 5-7 days to assess response to treatment. Educate parents on proper medication administration and the importance of completing the full course of antibiotics. Instruct parents to monitor for worsening symptoms, such as increased pain, fever, or drainage from the ear.
• Patient Education: Provided education regarding the use of acetaminophen for pain and fever management, proper antibiotic administration, and the importance of follow-up. Discussed potential side effects of amoxicillin. Instructed parents to contact the office if symptoms worsen or if new symptoms develop. Information about ear hygiene was reviewed.

Physician Signature: [Physician's Name], MD

Note: This is a sample SOAP note and should be adapted to reflect the specific findings and circumstances of each individual patient. The diagnosis and treatment plan should be based on the clinical judgment of the treating physician. This information should not be considered medical advice. Always consult with a healthcare professional for any health concerns.