Ms. J is 23 year-old female who presents to a local urgent care clinic where you are working as an APRN.
Ms. J complains of a left earache that has progressively worsened over the past 6 days. She describes a “constant ache.” She has a runny nose, cough, headache and has been feverish with intermittent chills. She said her temperature has been between 100 and 101.5. She has been taking acetaminophen, which helps with the fever but not the ear pain.
On examination, you note Ms. J has bulging tympanic membranes bilaterally, but her left tympanic membrane is erythematous and dull which has resulted in distorted landmarks. T 101.3°F, BP 128/76, HR 98, RR 22, HT 63”, WT 124 lbs
SOAP Note Instructions:
Utilize the patient description above to formulate your SOAP note assignment with the blank template provided separately. In addition to the case study above, you will have to supplement some information for yourself. For example, you may formulate your own social history, medical history, additional physical examination findings, etc. Be sure to review the grading rubric and the other attachments for this assignment as well.
