1
SOAP NOTE 6: EARACHE
SOAP Note
6 Earache
Spring Arbor
University Brett Locke
This study source was downloaded by 100000829907498 from CourseHero.com on 08-16-2021 18:59:17 GMT -05:00
https://www.coursehero.com/file/57084101/SOAP-note-6-Brett-Lockedocx/
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SOAP NOTE 6: EARACHE
Name: K.A. Date : 11/26/2019 Time : 11:15
DOB: 3/9/1982 Sex: Female
Subjective
CC: Earache
HPI: Patient is a kind 37-year-old caucasian female who presents to the clinic with complaints
of pain to right ear that initially presented 3 weeks ago and resolved on its own. She began to
experience right ear pain again yesterday and states this was sudden in onset. She states her ear
feels as though it is under pressure and everything sounds hollow. She noticed dry blood in her
ear yesterday but denies any purulent or clear drainage. She is scheduled to see her ENT
physician on Monday but is concerned about the pain through the holiday and over the
weekend. The earache is located on the right side. She has a history of tympanostomy tube
placement to the right ear due to recurrent ear infections. There is no history of recent
antibiotic usage, cold or upper respiratory symptoms, or recurrent otitis media assisted with the
earache. She has not traveled recently in an aircraft or engaged in scuba diving. She denies
nasal discharge, cough, fever, headache or sore throat.
Medications:
Coumadin 7.5 mg po 4 days weekly and 1.5 tablets 3 days weekly
Adult Aspirin 81 mg po daily
Lyrica 50 mg po qhs
Wellbutrin XL 300 mg po
daily
Butalbital-acetaminophen 50-325 mg po q 4 hrs prn. No more than 6 tablets daily
Cardizem CD 120 mg po daily
Xopenex HFA 45 mcg/ACT Inhalation Aerosol 1-2 puffs INH q4-6 hrs prn
Xyzal 5 mg po daily
Incruse Ellipta 62.5 mcg/Inhalation Aerosol Powder 1 puff inhaled daily
Imitrex 25 mg po x 1 prn migraine headache. May repeat after 1 hour if needed
Minivelle patch twice weekly
Allergies:
Demerol – anaphylaxis
Phenergan – anaphylaxis
PMI
Illnesses/Injuries
Childhood - Varicella
Adult- Hypertrophic cardiomyopathy/heart mumur/angina – managed by cardiologist;
GERD, osteoarthritis, migraines, asthma, atrial fibrillation, anxiety
SOAP NOTE 6: EARACHE
SOAP Note
6 Earache
Spring Arbor
University Brett Locke
This study source was downloaded by 100000829907498 from CourseHero.com on 08-16-2021 18:59:17 GMT -05:00
https://www.coursehero.com/file/57084101/SOAP-note-6-Brett-Lockedocx/
, 2
SOAP NOTE 6: EARACHE
Name: K.A. Date : 11/26/2019 Time : 11:15
DOB: 3/9/1982 Sex: Female
Subjective
CC: Earache
HPI: Patient is a kind 37-year-old caucasian female who presents to the clinic with complaints
of pain to right ear that initially presented 3 weeks ago and resolved on its own. She began to
experience right ear pain again yesterday and states this was sudden in onset. She states her ear
feels as though it is under pressure and everything sounds hollow. She noticed dry blood in her
ear yesterday but denies any purulent or clear drainage. She is scheduled to see her ENT
physician on Monday but is concerned about the pain through the holiday and over the
weekend. The earache is located on the right side. She has a history of tympanostomy tube
placement to the right ear due to recurrent ear infections. There is no history of recent
antibiotic usage, cold or upper respiratory symptoms, or recurrent otitis media assisted with the
earache. She has not traveled recently in an aircraft or engaged in scuba diving. She denies
nasal discharge, cough, fever, headache or sore throat.
Medications:
Coumadin 7.5 mg po 4 days weekly and 1.5 tablets 3 days weekly
Adult Aspirin 81 mg po daily
Lyrica 50 mg po qhs
Wellbutrin XL 300 mg po
daily
Butalbital-acetaminophen 50-325 mg po q 4 hrs prn. No more than 6 tablets daily
Cardizem CD 120 mg po daily
Xopenex HFA 45 mcg/ACT Inhalation Aerosol 1-2 puffs INH q4-6 hrs prn
Xyzal 5 mg po daily
Incruse Ellipta 62.5 mcg/Inhalation Aerosol Powder 1 puff inhaled daily
Imitrex 25 mg po x 1 prn migraine headache. May repeat after 1 hour if needed
Minivelle patch twice weekly
Allergies:
Demerol – anaphylaxis
Phenergan – anaphylaxis
PMI
Illnesses/Injuries
Childhood - Varicella
Adult- Hypertrophic cardiomyopathy/heart mumur/angina – managed by cardiologist;
GERD, osteoarthritis, migraines, asthma, atrial fibrillation, anxiety
