NR511 Week 2 SOAP Note 2017

Patient information:PADDY 4-year-old Male Caucasian

S: SUBJECTIVE DATA

Chief Complaint (CC):“Paddy has had a cold for a few and been talking about his ears popping and feeling stuffy”. “He woke up this morning and said his ear really hurts too. He also feels warm to me”.

History of present illness (HPI):

O-Patient’s mother stated he has had a cold for “a few” and the ear pain began this morning and he “feels warm” as per mother. When did the cold symptoms begin? Did you take his temperature? When did he start to feel warm? When did you start to feel your ears popping and feeling stuffy? When did the ear pain begin?

L- Which ear feels popping and stuffy? Do both ears? Which ear hurts?

D- Woke up and said his ear hurts and has had a cold for “a few”. When did you start to feel the cold symptoms? When do you think it started? How did the symptoms start? Have they been hurting ever since you first felt the discomfort or does it come and go?

C-Popping and feeling stuffy with ear pain. Does the outside of your ear hurt? Does the inside of your ear hurt? Does your throat hurt? Does your nose feel stuffy too? Have you been having difficulty hearing? Do you feel like if you have water in your ear?

A-Does anything make you feel worse? Does anything make your ear ache worse?

R-Does anything relieve your symptoms?

T-Have you taken any medicine? Did your mom give you anything to make you feel better?

S-Using Wong-Baker visual scale from 1-10, 10 being the worst, what would you say your pain is at right now? And what would you say your pain was at when you felt the ear start popping? Do you have any nausea?

Patient information:Tommy 4-year-old Male Caucasian

S: SUBJECTIVE DATA

Chief Complaint (CC):“Tommy woke up in the middle of the night saying his ear hurt so badly it woke him up. He says it hurts to touch.”

History of present illness (HPI):

O-Patient’s mother stated Tommy woke up in the middle of the night saying his ear hurt so badly it woke him up. He says it hurts to touch. Did this happen last night? If not, then when? Does it still hurt? Does it come and go? Has this happened before?

L- Which ear hurts? Do both ears hurt? Where exactly do you feel the pain in your ear? Does the pain also radiate toward your throat?

D- Ear pain woke him up from his sleep. Did the ear pain begin last night? Were you able to go back to sleep? Did you feel pain in your ear before that? When would you say the ear pain started?

C-How did the symptoms start? Does the outside of your ear hurt if you touch it? Does the outside of the ear hurt without touching it? Have you been having difficulty hearing? When your ear hurt how did it feel? Was it a stabbing pain? Have you had anything inside your ear lately? Does your throat hurt? Does your nose feel stuffy?

A-Does anything make your ear ache worse?

R-Does anything relieve your symptoms?

T-Have you taken any medicine? Did your mom give you anything to make you feel better?

S-Using Wong-Baker visual scale from 1-10, 10 being the worst, what would you say your pain is at right now? And what would you say your pain was at when you felt the ear ache start? Is the pain better now than before? Do you have any nausea?

Patient information:Mary 40-year-old Female Caucasian

S: SUBJECTIVE DATA

Chief Complaint (CC):“Sore throat”

History of present illness (HPI):

O-Since yesterday. When did the sore throat start? Were you doing something specific when it hurt or did you just wake up with sore throat?

L- Where exactly does it hurt on your throat? Do you have pain anywhere else? Noticed any swelling?

D- Since yesterday. How long has it been sore?

C-How did the symptoms start? Does your throat feel scratchy? Does your throat feel swollen? Do you have any other symptoms such as ear ache? Headache? Cough? Mucous? Have you noticed any swelling behind ears, neck?

A-Swallowing makes it worse. Does anything make your throat ache worse aside from swallowing?

R-Does anything relieve your symptoms?

T-Have you taken medicine or treatment for the sore throat?

S-On a scale from 1-10, 10 being the worst, what would you say your pain is at right now? And what would you say your pain was at when you felt the throat ache start? Is the pain better now than before? Do you have any nausea?

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