NURS 6541N Week 7 Assignment 2 PT1 SOAP NOTE

NURS 6541N Week 7 Assignment 2 PT1 SOAP NOTE

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SUBJECTIVE DATA Chief Complaint (CC): “My left ear hurts.” History of Present Illness (HPI): A 5-year-old Caucasian female with mother. She states that B.S. started complaining of left ear pain... last night and keeps tugging on her ear. She states that she has not complained until late last night when she started to go to sleep. B. S. states that her “ear just hurts really bad”. Mother reports that after her bath last night she attempted to clean B.S. ears out and that seemed to aggravate the pain. Mother reports that B.S. has had some clear nasal drainage with nasal stuffiness x 3 days with no fever. Mother states that she gave B.S. some Motrin 5ml and she soon fell asleep. Mother reports that when B.S. woke up this morning she had a temporal temperature of 101.0F and B.S. was complaining of more pain in that ear. Using the faces pain scale B.S. indicates that her ear pain made her feel like the third face on the pain scale. Medications: Motrin 5ml PO once last night. General: B.S. states that her ear has been hurting all night and she did not sleep well. Mother states that she woke up this morning crying with fever of 101.0F and asked to go to the doctor. Mother states she has been whining and wants to be held, with no interest in playing. Skin: Reports some mosquito bites on bilateral arms that itch. Denies any injuries or open sores. HEENT: Denies headache. Denies vision problems. Denies putting anything into the ears. Left ear pain, denies drainage. Reports some nasal congestion at times with clear drainage, reports no pain. B.S. denies any throat pain. Neck: Denies stiffness or difficulty swallowing. [Show More]