Describe Otitis media with effusion soap note
patient: DX: right otitis media with effusion
With this patient in mind, address the following in a SOAP Note:
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.
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Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues. Otitis media with effusion soap note essay example.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Primary Diagnosis of Otitis Media with Effusion Through the SOAP (Subjective, Objective, Assessment, Plan) Algorithm, Differential Diagnoses, Management, and Case Reflection
Patient Initials: _______ Age: _______ Gender: _______
Chief Complaint (CC): There is some pain and fullness of the right ear as reported by the child Otitis media with effusion soap note essay example. But the mother reports that the child is unable to hear well in close proximity and is lately having trouble breathing and sleeping.
History of Present Illness (HPI): A 21/2 year-old Caucasian male child was brought by his mother to the clinic with the main complaint of having a feeling of fullness in the right ear and inability to hear properly with that side. The mother also reports that the child has been having trouble breathing while sleeping, often having to sleep with his mouth open. No fever is reported by the mother. The boy is still fed from a bottle, especially when the mother wants him to sleep. The boy feeds well and is achieving his milestones as required. Otitis media with effusion soap note essay example.
The inability to hear well started one week ago, occurs from distances of about one meter, one has to raise their voice for the child to hear and turn, and occurs all the time since start. The sleep disturbance started about three days ago, occurs at night, is associated with the inability to breathe well in sleep, and is relieved by opening the mouth and using it to breathe. For the child, the pain is in the head but he does not know when it started. It is not too much (he cannot exactly rate it), and occurs on and off while able to be relieved by drinking milk. The fullness as reported by the child is in the head, started “a long time ago,” comes on and off, is relieved by yawning, and is not “too bad.”
There were no major discrepancies between what was reported by the parent and what the child reported, adjusting for the child’s age. Otitis media with effusion soap note essay example.
Medications: For his allergy to the environmental factors stated above, the boy is on Zyrtec (cetrizine) syrup 5 mg once daily. However, he is only given the medication when he has a runny nose like at present.
Allergies: The patient is allergic to airborne particulate matter such as pollen grains and dust. He usually gets a serious runny nose for a day or two on exposure to these allergens. He also at times develops these same symptoms when he is exposed to cigarette smoke Otitis media with effusion soap note essay example.
Past Medical History (PMH): The child has a previous history of being treated as an outpatient for Acute Otitis media (AOM) about a month ago, and an admission for pneumonia when he was one year old. He has no significant history of childhood illnesses.
Past Surgical History (PSH): There is no significant surgical history for the child.
Personal/Social History: The child is able to feed normally unassisted and is meeting his developmental stages on time. He has no delayed milestones. He plays normally with other children, his siblings, and his parents.
Immunization History: The boy received all the childhood immunization vaccines needed, including for pneumonia and influenza Otitis media with effusion soap note essay example.
Significant Family History: There is a family history of allergy on the maternal grandmother, and asthma on the paternal grandmother. Both parents have no significant illnesses. The child was a normal pregnancy and delivery with a good Apgar score and an uneventful neonatal period.
Lifestyle: The boy’s father is a smoker, although he never smokes in the house. However, the mother reports that the boy has a tendency of running outside to his father when he is smoking. Otitis media with effusion soap note essay example.
Review of Systems:
General: The boy is normal size and weight for his age. There are no changes in weight since the last one was taken. There is no obvious weakness or fatigue as the child is playful like any other child his age. He also has no fever (T = 37.1°C). He has no obvious language or cognitive deficiencies.
HEENT: The boy says his head is heavy and sometimes feels a headache. He says he can see well, but has some difficulty hearing speech using his right ear. He also says the mucus coming out of his nose is bothering him. He has no difficulty in swallowing solid food or drinks.
Respiratory: Unremarkable. He has no pain in the chest, is not coughing, and is not laboring to breathe.
Gastrointestinal: The mother reports normal bowel movements Otitis media with effusion soap note essay example.
Genitourinary: The mother reports normal bladder activity.
Psychiatric: There is no obvious cognitive or developmental anomaly from the child’s speech. He is meeting all his developmental goals as envisaged.
Allergic/Immunologic: Confirmed sensitivity to particulate environmental allergens, from the mother.
OBJECTIVE DATA (Physical Exam, Imaging, & Laboratory Tests)
Vital signs: The patient has a temperature of 37.1°C, a respiratory rate of 28 breaths per minute, and a heart rate of 90 beats per minute. He weighs 13.6 kilograms at presentation, and the mother reports that he weighed 13.5 kg the last time he was seen at the child welfare clinic. His height is 85 centimetres. Using weight as 30 pounds and height as 33.5 inches, the calculated BMI for this boy is 18.8. This puts the BMI-for-age percentile for this boy at the 96th percentile, or obesity (CDC, 2019).
General: The child is in good general condition, with normal posture and gait. He is active and playful for a child of his age. His body hygiene and grooming are satisfactory and not of a child from a low socio-economic background. There are no obvious neurological deficits and the child is oriented in space, time, place, and person. He has normal affect or emotions, mannerisms, and reactions for a child his age. No abnormal body odors and/ or breath are detectable.
HEENT: The head is normal for body and age. The eyes are unremarkable. On examination of the throat, the adenoids appear enlarged. There is no pallor. However, the boy has a runny nose which the mother has to wipe from time to time. There are no polyps or inflammation of the nose. Pneumatic otoscopy and tympanometry (Zakrzewski & Lee, 2013) of the right ear reveals a retracted tympanic membrane with an air-filled interface visible. The fluid behind the membrane is yellowish, and there is prominence of the lateral processes. There is also no mobility of the tympanic membrane. Otitis media with effusion soap note essay example.
Neck: There is no cervical lymphadenopathy.
Chest: The rib cage looks symmetrical with no chest indrawing.
Lungs: Auscultation reveals normal air entry. There no rhonchi, rales, or wheezing. A plain chest X-ray is done as a precaution, given the previous medical history of pneumonia.
Heart and Peripheral, Vascular (Cardiovascular): There are normal heart sounds on auscultation. There is normal peripheral circulation with no pallor or blue discoloration. A full blood count (CBC) is to be done to rule out any infection (leucocytosis) and the differential diagnosis of acute otitis media or AOM (Higgins, 2018).
Abdomen: Normal bowel sounds with no tenderness on palpation Otitis media with effusion soap note essay example.
Neurological: No obvious neurological deficit. Common reflexes are normal.
ASSESSMENT: Primary diagnosis: Otitis media with effusion (OME). First differential diagnosis: Acute otitis media (AOM). Second differential diagnosis: Myringitis. Third differential diagnosis: Cystic fibrosis (Higgins, 2018).
Physical examination is the mainstay of OME diagnosis. This involves the use of pneumatic otoscopy, tympanocentesis, and tympanometry (Higgins, 2018; Al-Juboori et al., 2014; Zakrzewski & Lee, 2013; Robb, & Williamson, 2012; American Academy of Pediatrics, 2004). Because of the claim of some pain by the child and the past medical history; acute otitis media (AOM) is the first likely differential diagnosis, and must be ruled out since it causes inflammation as opposed to OME (Higgins, 2018). Also, it is the most recent illness the child was treated for (just about a month ago), and may not have been completely controlled. It is followed by Myringitis, which is inflammation of the middle ear and the tympanic membrane. Lastly is the remote differential diagnosis of cystic fibrosis (Higgins, 2018). In this case, the thick secretions of cystic fibrosis would be responsible for the effusion and blockage of the Eustachian tube. Otitis media with effusion soap note essay example. Pneumonia which the child has suffered from in the past is ruled out by the chest X-ray and the absence of fever, meaning it is well controlled and was adequately treated.
Treatment Plan: The goals of treatment for OME are three – to reduce or stop the effusion causing conductive hearing loss, to return hearing to normal, and to prevent recurrence (Zakrzewski & Lee, 2013). The use of antibiotics, decongestants, antihistamines, and steroids is not recommended because the evidence does not support their efficacy in treating OME (Zakrzewski & Lee, 2013; American Academy of Pediatrics, 2004). The recommended evidence-based treatment modalities are autoinflation, watchful waiting (doing nothing), and surgery (Higgins, 2018; Al-Juboori et al., 2014; Zakrzewski & Lee, 2013; Robb, & Williamson, 2012; American Academy of Pediatrics, 2004). Autoinflation involves opening up the Eustachian tube by increasing the intranasal pressure. Surgery involves adenotonsillectomy and/ or myringotomy; and is only resorted to if the OME fails to resolve itself through watchful waiting or observation for 3 months (Higgins, 2018; Al-Juboori et al., 2014; Robb, & Williamson, 2012). Otitis media with effusion soap note essay example. Other alternative treatments like homeopathy have been shown to be ineffective (Robb, & Williamson, 2012).
Health Promotion: 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. Moreover, the child should not be fed with his bottle while lying on his back. This is because research shows that this is an important cause of OME when milk enters the Eustachian tube causing inflammation and blockage (Higgins, 2018).
Disease Prevention: The American Academy of Pediatrics recommends that the child who has had OME be put under surveillance, with re-examination at intervals of at least 3 months (American Academy of Pediatrics, 2004).
REFLECTION: The lesson learnt from this experience is that you can actually manage some conditions (like OME) by just observing and doing nothing, based on solid evidence. And the ‘ah-ha’ moment came with the differentiation between AOM and OME, with the former causing inflammation and fever and not the latter. Otitis media with effusion soap note essay example.
Preceptor Signature and Date
(Signature is REQUIRED for this assignment).
Al-Juboori, A.N., Al-Aqeedee, A.A., & Saeed, H.D. (2014). Otitis media with effusion in children: A follow up study in West Baghdad, Iraq. Journal of Communication Disorders, Deaf Studies & Hearing Aids, 2(4), 1-5. Doi: 10.4172/2375-4427.1000122
American Academy of Pediatrics (2004). Clinical Practice Guidelines: Otitis media with effusion. Pediatrics, 113(5), 1412-1429, https://www.google.co.ke/url?sa=t&source=web&rct=j&url=http://www.antibioticos.mscbs.gob.es/PDF/AAP_otitis_media_with_effusion.pdf&ved=2ahUKEwidpJiJ8LvkAhXxyYUKHfc8DzoQFjAQegQIBxAB&usg=AOvVaw1N-oE5C7AiXC3ICjPDM0sh&cshid=1567762186200
Centres for Disease Control and Prevention [CDC] (2019). Child and teen BMI calculator. Retrieved 6 September 2019 from https://www.cdc.gov/healthyweight/bmi/calculator.html
Higgins, T.S. (2018). Otitis media with effusion. Retrieved 6 September 2019 from https://emedicine.medscape.com/article/858990-overview
Robb, P.J. & Williamson, I. (2012). Otitis media with effusion in children: Current management. Paediatrics and Child Health, 22(1), 9-12. Doi: 10.1016/j.paed.2011.03.002
Zakrzewski, L. & Lee, D.T. (2013). An algorithmic approach to otitis media with effusion. The Journal of Family Medicine, 62(12), 700-706, https://www.mdedge.com/familymedicine/article/79105/pediatrics/algorithmic-approach-otitis-media-effusion Otitis media with effusion soap note essay example