Soap Note

Use the Episodic/Focused SOAP Template provided in additional materials (what is required in each section is provided) and create an episodic/focused note about the patient in the case study provided below. Provide evidence from the literature to support diagnostic tests that would be appropriate. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Martha brings her 11-year old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer. James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has aprominent tan. When you ask him how he’s been spending his summer, James responds that he’s been spending a lot of time in the pool.

 

All resources must be within the last 5 years 

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