NURS-6512 DQ 5/NURS 6512: Advanced Health Assessment & Diagnostic Reasoning INITIAL POST SOAP Note Case Study #3 Complete Study Guide_ Guaranteed Success.

SOAP Note Case Study #3 Patient Information: JR, 11, Male, Hispanic S. Chief Complaint: Right Earache History of Present Illness: James, a 11-year-old Hispanic male, presents to the clinic with right mild earache for the past two days. At the moment he scores the pain a 5/10. However, he reports that his earache becomes worse when he lays down to sleep leaving his pain at 8/10. He did not experience any earaches in the past and did not notice any discharge from his ear. His grandmother states that he felt warm but did not confirm his body temperature with a thermometer. James reports that he has been taking Tylenol for the pain which does not completely relief pain. Current Medications: OTC Tylenol 325mg Tablets every 4 hours as needed for pain Allergies: Shellfish Past Medical Hx: No chronic health conditions. All childhood immunizations up to date. Last Influenza immunization October 2017. Refused Pneumococcal immunization. No past hospitalizations or surgeries. Social Hx: Patient is a 6th grade student and member of the swimming team. The patient enjoys being in the water during h