Respond to other students SOAP notes with substantive comments in APA format.

Respond to other student’s SOAP notes with substantive comments. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.The postings should be at least one paragraph (approximately 100 words) and include references.

1. References and citations should conform to the APA 6th edition.
2. Remember: Please respect the opinions of others, even if their views differ. In other words, disagree professionally and respectfully.Plagiarism is never acceptable – give credit when credit is due – cite your sources

Response from Erika

S: A 3-year-old female patient presents to the clinic complaining of right ear pain for the last two days. The patient rates the pain as a 6 in the Wong-Baker FACES Pain Rating Scale. The patient’s mother reports the patient having a runny nose, nasal congestion, and cough for about a week that just resolved two days ago. Patient also had a temperature of 102 F yesterday and today. Patient has also been more lethargic and has had hearing problems recently.

O: VS: T 102.2 F, RR 20, HR 84, BP 112/70, SpO2 99%, Wt 14 kg, Ht 92cm. Patient alert and oriented and in no apparent distress. PERRLA, ears clean bilaterally with minimal cerumen, left tympanic membrane pearly gray with positive light reflex, right tympanic membrane red and bulging with diminished light reflex with no drainage.

A: Acute Otitis Media

P: Amoxicillin PO BID x10 days for infection and Tylenol suspension for fever and pain. Follow up if no improvement or worsening with antibiotic therapy.

Acute Otitis Media

Acute Otitis Media is considered as one of the most common ear infections in children. By the time children are 3 years of age, almost all children would have experienced acute otitis media at least once in that time period (Marchisio et al, 2014). Acute otitis media is usually mild and will eventually resolve in a couple of days. The complications usually involve the tympanic membranes. Modifiable child related risk factors are the first line of defense in preventing acute otitis media. These include decreasing daycare attendance, bottle-feeding, secondhand smoke, and pacifier use. Pneumococcal and influenza vaccinations are also effective preventative measures (Marchisio et al, 2014). Marchisio et al (2014) also mentions “Oral and topical probiotics, xylitol, vitamin D and complementary and alternative medicine remain intriguing options for rAOM prophylaxis, but current data are insufficient for recommending their use.”

Macular Degeneration

“Age-related macular degeneration (AMD) continues to be the most common cause of irreversible central vision loss in developed countries, affecting 25-35 million people worldwide” (Nussenblatt et al, 2014). There are about 1.7 million people in the United States that are affected by AMD. Risk factors such as smoking, dietary intake, and body mass index are correlated with AMD (Nussenblatt et al, 2014). Preventing AMD can be directed towards smoking cessation, eating a well balanced diet along with plenty of exercise.

Response from Megan

S:

Pleasant 21 yo F presents to clinic to obtain pre employment physical for summer job. Pt has no complaints at this time. No current medications and no past surgeries.

O:

Vital Signs: BP: 118/65, HR: 78, O2: 99%, T: 98.7F, RR: 13, BMI: 22

Integumentary: Normal in appearance, texture, and temperature. Color appropriate for ethnicity.
Head & Neck: Trachea midline, no palpable masses or swollen lymph nodes.
EENT: Pt wears contacts, PERRL. Ears have no drainage, nasal mucosa normal, no drainage. Tonsils present.
Cardiovascular: RRR, S1 and S2 heard with no additional sounds.
Respiratory: Lungs clear throughout, no adventitious sounds. Chest expansion equal bilaterally. No cough.
Gastrointestinal: Normoactive bowel sounds x4 quadrants. No tenderness or organomegaly.
Back/Spine: Full range of motion, spine is midline. Gait WNL.
Extremities: Full range of motion with no limitations. Pulses present bilaterally on upper and lower extremities, radial and pedal pulses +3/
Neurological: Motor and sensory examination of upper and lower extremities are normal with no limitations and symmetrical movement. Reflexes in tact.

A:

1. Wellness exam

P: Pt to return in 1 year for annual physical exam.

Graves Disease: Exophthalmos can be the result of an overactive thyroid. This condition is protrusion of the eyeball or eyeballs (Bickley, 2014). While uncommon, the optic nerve can be compressed during this condition causing impairment in sight. One way to prevent vision changes due to this condition is by correcting the underlying problem of overactive thyroid. By correcting this often times the exophthalmos will resolve.

Ear Barotrauma: can be caused by sudden changes in pressure such as in flying or scuba diving (Moore & Gotter, 2016). One symptom of ear barotrauma includes difficulty hearing or a slight hearing loss. One prevention tactic to avoid ear barotrauma is by using an antihistamine or decongestant prior to taking part in an activity that has the risk of barotrauma (Moore & Gotter, 2016).

References

Bickley, L. (2014). Bates’ Guide to Physical Examination and History-Taking. Eleventh, North American Edition: Lippincott Williams & Wilkins: ISBN 1609137620

Moore, K., & Gotter, A. (2016). Ear Barotrauma. Retrieved from: www.healthline.com/health/ear-barotrauma