PRAC 6541 Week 3 Assignment 1: Episodic SOAP Note for Acute Otitis Media

Assignment Overview

Write an episodic SOAP note based on a child you assessed during your practicum within the last three weeks. The case should focus on a probable diagnosis of acute otitis media and should reflect a real clinical encounter or a closely simulated practicum case that matches the course expectations. Use the SOAP format to present the patient history, examination findings, differential diagnoses, treatment plan, and a short reflection on your assessment process.

Your note should read like a primary care clinical document rather than a classroom essay. Use concise clinical language, include only relevant information, and make sure the subjective and objective data support the assessment and plan.

Clinical Context

Acute otitis media is usually identified through symptoms such as ear pain, fever, irritability, and a bulging or erythematous tympanic membrane on exam. AOM is commonly managed with pain control and, in selected children, high-dose amoxicillin; observation for 48 to 72 hours is also appropriate in lower-risk cases. The strongest documentation will connect the parent’s report, the child’s account, the ear exam, and the management choice in a single logical chain.

SOAP Requirements

Subjective

Document the chief complaint, history of present illness, and any relevant discrepancies between the child’s report and the parent’s report. Include pertinent positives and negatives using LOCATES or a comparable symptom structure. Add relevant past medical history, surgical history if relevant, family history, social history, medications, and drug or food allergies.

Objective

Include vital signs with BMI when appropriate, general appearance, heart and lung findings, and a focused physical examination that supports the diagnosis. For otitis media, the highest-value findings are otoscopic findings such as tympanic membrane bulging, erythema, reduced mobility, effusion, and the presence or absence of otorrhea. Do not add broad systems or special exam maneuvers that do not help confirm or exclude the diagnosis.

Assessment

Provide at least three differential diagnoses in priority order unless the case clearly supports fewer reasonable options. The primary diagnosis should be acute otitis media when the symptoms and exam findings match guideline criteria, especially bulging tympanic membrane with acute ear pain. Justify the diagnosis using the data from the subjective and objective sections rather than repeating the label alone.

Plan

Include diagnostics if needed, the medication plan, pain control, non-pharmacologic advice, parent education, and follow-up instructions. High-dose amoxicillin is first-line when antibiotics are indicated, while acetaminophen or ibuprofen may be used for pain relief. Topical anesthetic ear drops may be mentioned only when appropriate and only if the tympanic membrane is intact, since guidance cautions against topical drops when perforation is possible.

Reflection

Write a brief reflection on one clinical insight gained during the encounter and one thing you would do differently next time. The reflection should show clinical reasoning, not generic gratitude or narrative filler. A strong reflection might note that ear pain in children can be confused with a foreign body, otitis externa, or referred pain, so a more careful ear-history question could improve future assessments.

Marking Focus

• Accuracy and completeness of the subjective history.
• Appropriate, diagnosis-linked objective findings.
• Reasonable differential diagnoses and a defensible primary diagnosis.
• Evidence-based plan, including pain management and follow-up.
• Clear reflection showing learning from the encounter.

Sample Answer Excerpt

A 4-year-old child presented with a three-day history of right ear pain, fever, and irritability, with the parent reporting that the child initially blamed a possible insect in the ear. The child denied ear blockage and denied hearing a fluttering sensation, which made a foreign body less likely. Otoscopic examination showed a bulging, erythematous right tympanic membrane with reduced light reflex and no visible bony landmarks, which supports acute otitis media more strongly than otitis media with effusion. The left ear appeared normal, which helped narrow the problem to a unilateral acute process. Heart and lung examination were unremarkable, which reduced concern for a broader systemic illness. The plan would include pain relief, appropriate antibiotic therapy when clinically indicated, and clear return precautions if symptoms fail to improve within 48 to 72 hours. A useful clinical lesson is that a child’s first explanation is not always the best explanation, so the examiner must test each possibility against the physical findings and the history.

The management choice should follow the child’s age, symptom severity, and ability to tolerate observation. Current guidance supports high-dose amoxicillin when antibiotics are needed, while observation remains reasonable in selected lower-risk children, especially when follow-up is reliable. That distinction matters because many cases improve without immediate antibiotics, and unnecessary prescribing can increase adverse effects and resistance. In practice, the exam should focus on the tympanic membrane rather than broad specialty maneuvers that do not change the diagnosis. A concise note that records the child’s temperature, pain severity, ear exam findings, and follow-up plan usually earns more credit than a long but unfocused narrative.

Students often lose marks when they list several diagnoses without ranking them by probability or fail to show why the primary diagnosis is the best fit. A stronger approach is to compare acute otitis media with otitis media with effusion, otitis externa, and a foreign body only if those conditions are actually plausible from the history and exam. The plan should also avoid outdated or unsupported details, because current guidance emphasizes analgesia, selective antibiotic use, and reassessment if the child does not improve after 48 to 72 hours. When the note is written in that order, it reads like real clinical reasoning instead of a copied template. That style also matches the way many nursing SOAP rubric categories reward precision, relevance, and clinical judgment.

Suggested references should be anchored in current guidance, not older blog-style summaries. The most defensible clinical sources in your excerpt are NICE’s acute otitis media prescribing guidance and the AAFP evidence review, which both support the same core diagnosis and treatment pattern. Three to five verifiable references from 2018 to 2026 would be:

Venekamp, R. P., et al. 2025. Antibiotic treatment of acute and recurrent otitis media in children. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC11844117/

American Academy of Family Physicians. 2019. Otitis Media: Rapid Evidence Review. Available at: https://www.aafp.org/pubs/afp/issues/2019/0915/p350.html

National Institute for Health and Care Excellence. 2022 update. Otitis media (acute): antimicrobial prescribing. Available at: https://www.nice.org.uk/guidance/ng91

Haynes, D. S., et al. 2020. Clinical practice guidelines for acute otitis media in children. BMJ Open, 10(5). Available at: https://bmjopen.bmj.com/content/10/5/e035343

American Academy of Family Physicians. 2013. Otitis Media: Diagnosis and Treatment. Available at: https://www.aafp.org/pubs/afp/issues/2013/1001/p435.html

Write a focused SOAP note for a child with acute otitis media, including subjective data, objective findings, differential diagnoses, treatment plan, and reflection in practicum format.

• Prepare a 1 to 2 page episodic SOAP note for acute otitis media with assessment, plan, reflection, and evidence-based pediatric management details.
• Create a SOAP note that documents a pediatric ear infection case with clear history, exam findings, priority diagnosis, treatment, and follow-up instructions.

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Week 4 Practicum SOAP Note

The next likely assignment in this sequence is another episodic SOAP note or a related pediatric assessment task built around a different common primary care condition. It usually asks the student to document a new patient case, organize the encounter in SOAP format, and support the diagnosis with relevant subjective and objective data. The rubric typically keeps the same structure, with marks for history, exam findings, assessment logic, management plan, and reflection.

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In many Walden-style practicum courses, the follow-up task often shifts from ear infection to another acute pediatric complaint, such as URI, pharyngitis, conjunctivitis, or a similar focused diagnosis. The safest preparation is to keep the same SOAP discipline and study the diagnostic criteria, treatment choices, and follow-up expectations for the next common pediatric presentation.