Case:A parent brings her two-year-old son to your office because

Case:A parent brings her two-year-old son to your office because of a chief complaint of fussiness and tugging at his right ear for the past two days. He has had coughing and a runny nose for about 5 days that has been treated with saline nasal spray and a humidifier. He has a low-grade fever of about 101 degrees F (38.3 degrees C) axillary for the past two days. Both parents smoke cigarettes. He attends daycare. His past medical history is significant for ear infections in the past, with his last otitis media episode 5 months ago, treated with amoxicillin. His immunizations are up to date, including 13-valent pneumococcal conjugate vaccine. Exam: VS T 38.4, P 100, RR 28, BP 100/65. He is active, alert to his surroundings and otherwise in no distress. HEENT: Right tympanic membrane is erythematous and bulging, with poor mobility on pneumatic otoscopy. Left TM is clear with good mobility. Throat is non- erythematous. There are small cervical lymph nodes. Lungs are clear to auscultation. The rest of the examination is normal. Can you please help me fill out the following SOAP note to give me and idea how to do it? First Name of the Patient: DOB: Sex assigned at birth: Gender Identity: Vitals: Subjective Findings: Chief Complaint (CC): History of Present Illness (HPI): Remember OLDCARTS Onset- Location- Duration- Characteristics- Alleviates/Aggravates- Radiates to where? Relevance- Related to- Treatments to date- Significance- Health History: Allergies Medications Past Medical History Past Surgical History Family History Social History Sexual/Reproductive History (if applicable) Health promotion/immunization history Review of Systems (ROS): Try to organize this head-to-toe Try to include only pertinent positives and negatives Objective Findings: VITAL SIGNS: BP Pulse Respirations Temperature PaO2 (room air) Weight Height BMI Skin Head Eyes ENT/Mouth Neck Cardiovascular Respiratory Breasts (as indicated) GI GU (as indicated) Musculoskeletal Neurologic Lymphatic Mental health/cognitive A: Differential diagnoses Plan for Treatment: Diagnostic plan Therapeutic plan Pharmaceutical plan Non-pharmaceutical plan Basic/advanced procedures Consultations Educational plan Follow-up

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