Monroe College NURSING 812  Adult Assessment  SOAP Note: Otitis Media Patient initial and age: C.M., 2 years old Gender: Male Race: White

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Monroe College NURSING 812  Adult Assessment  SOAP Note: Otitis Media Patient initial and age: C.M., 2 years old Gender: Male Race: White Chief Complaint: Per mom- "My child has been very fus... sy since around noon today which is not like him, she states he is a really happy baby.” She states “she was trying very hard to treat him herself because she thought it was just a little common cold and runny nose from being at day care all week.” She also stated “she had been treating him herself with liquid Tylenol all day Friday and then his temperature went up on Saturday morning to 101.0 so she decided to bring him in for treatment.” History of Present illness: Per mother, patient is currently going to day care during the week and she bought him home on Friday with a runny nose and Past Medical History: Allergies: NKDA Medical History: No medical history Surgeries: None Vaccinations: Mother states “she does not know specific dates of vaccines but states all immunizations are up to date.” Medication List: NKDA Family History: Mother-Tonsillectomy, Appendectomy Father- No history Social History: Full time in day care. Review Of System: (The information given per mother, patient sleeping throughout the exam) Constitutional- Mother states he has fever, no chills, or weight loss Head/Eyes- Mother states does have drainage from eyes. Mother denies any pain or itching to bilateral eyes. Patient does not use eye glasses. ENMT- Mother states he has had recent nose drainage but no bleeds, sinus congestion, post nasal drainage or reports of sore throat. Cardiovascular- Mother denies any unusual shortness of breath with age appropriate activities. No recent complaints of chest pain. Respiratory- Mother denies any known cough, congestion, or hemoptysis. [Show More]

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