Learning to Write Case notes Using the SOAP Format

Running head: SOAP FORMAT
Treatment plan for common cold- SOAP format
Name of the Student:
Name of the University:
Author Note:
Identification\ Problem
Recognition
Patient initial
N Nationality Saudi Problem
Statement
Age 7 years Source of
information
Patient and mother “she has a p
in the right
and has h
runny nose
the past 9 day
Sex
Female Culture/
Religion
Sunni muslim
A seven-year-old female accompanied by her mother presented with a pain

1
SOAP FORMAT
SUBJECTIVE DATA
HPI
the right ear for two days with a runny nose and cough for the last 9 da
initially clear and dense but green and thick at present with decreased phleg
No fever or chills reported.
Birth History
Full-term vaginal delivery of the baby with no particular complication.
PMH
No past medical conditions or problems noted. The 7-year check-up tak
five months ago displayed that she was among 90th percentile for height a
weight.
Surgical
History
No prior surgical history.
Family
History
She lives at her house with parents, two twin elder brothers and a pater
grandmother with all the essentials. Her father works as the regional manag
of a restaurant chain. Her mother does not work outside home.
Social History
She studies in the primary school in grade 1 and does well at school. S
recently visited the waterpark in Dubai with her family.
Allergies No particular drug or food allergies are observed.
MEDS.
Children’s paracetamol was taken about 8 hours gao.
Immunization
She has taken all the childhood vaccines.
ROS
ROS
HEENT
Head: Refuses headache.
Eyes: physical examination reveals conjunctiva without redness
drainage. Lids without swelling.
Nose: runny nose and cough since 9 days. Thick and clear na
drainage initially and light green at present. Refuses tenderness
the frontal and maxillary sinuses.
Mouth: symmetric and full movement of the oropharynx.
Ears: Both the ears appear the same and no tenderness observ
Pain reported in the right ear for the last 2 days.
Temporomandibular joint (TMJ): No mastoid redne
tenderness or swelling observed in physical examination
Throat: Cough reported which worsens in the morning. Cou
with scanty phlegm.
Face and neck: lymph nodes not enlarged.
RESP.
Breathing with nasal drainage and thick cough, which worsens
the morning.
CV
No remarkable abnormality observed or reported.
GI\GU
Denies any nausea, vomiting, diarrhoea or constipation. Refu
any abdominal pain.
MSK
No particular abnormality observed.
CNS
No particular abnormality reported.
SKIN
No burn, swelling or abnormality observed.
Mental No distress reported.

2
SOAP FORMAT
OBJECTIVE DATA
&
PHYSICAL
ASSESSMENT
V\S
Temperature: 37.2C
BP: 102/78 mmHg
Pulse:88
RR: 18 B/min
Length and weight for age is in the percentile: 90
Plan
The most likely diagnosis includes acute otitis media (AOM) which resulted in ear pain
and can be diagnosed with a tympanometry test to check the damage of the eardrum.
Pharmacol
ogical
Treatment
DRUG General Considerations
 Paracetamol
and ibuprofen
 Amoxicillin or
amoxicillin-
clavulanate
Paracetamol and ibuprofen act as analgesics and
anti-pyretics to relieve the pain of the patient
(Kanabar 2017).
Amoxicillin is an antibiotic which, is used to treat
the infection of AOM. This cost-effective
medication of amoxicillin can be given to
patients above 2 years without any allergy to
penicillin (Shaikh et al. 2017).
Follow
Up
The patient will have to follow –up with the pediatrician after 48 to 72 hours to
check the effect of amoxicillin.
Education
Lifestyle and home remedies
 Keep the medications out of the reach of the child.
 Apply a warm and moist cloth on the infected ear.
 Check for fever.
 Nasal vaporizers can also be given to ease the runny nose (Bouwer
2015).
Referral
No specific referral is required at present. If the pain continues with signs of
hearing loss, she may be referred to an otolaryngologist.
Learning
Resources
Bouwer, A., 2015. Chronic nasal congestion: ear, nose and throat. SA Pharmacist's
Assistant, 15(2), pp.12-13.
Kanabar, D.J., 2017. A clinical and safety review of paracetamol and ibuprofen in
children. Inflammopharmacology, 25(1), pp.1-9.
Shaikh, N., Dando, E.E., Dunleavy, M.L., Curran, D.L., Martin, J.M., Hoberman, A. and
Smith, K.J., 2017. A cost-utility analysis of 5 strategies for the management of acute
otitis media in children. The Journal of pediatrics, 189, pp.54-60.
Questions and answers:

3
SOAP FORMAT
Question 1
The most common evolution of nasal drainage in acute otitis media is clear to yellow or light
green in the majority of the children. The nasal drainage or mucus secreted by the nose as a
result of AOM-induced cold evolves from colorless to white, yellow or light green in color
during different stages of incubation of the pathogen (Eccles and Wilkinson 2015).
Question 2
The physician did not check the soreness of the throat and tympanic membrane inflammation in
the patient. Cold symptoms such as sore throat are indicative of acute otitis media (Kardos and
Malek 2017). The inflammation of the tympanic membrane is conclusive of AOM (Picardo and
John 2018).

4
SOAP FORMAT
References
Eccles, R. and Wilkinson, J.E., 2015. Exposure to cold and acute upper respiratory tract
infection. Rhinology, 53(2), pp.99-106.
Kardos, P. and Malek, F.A., 2017. Common Cold–an Umbrella Term for Acute Infections of
Nose, Throat, Larynx and Bronchi. Pneumologie, 71(04), pp.221-226.
Picardo, N. and John, M., 2018. Otitis media in children. Current Medical Issues, 16(1), p.1.