SOAP NOTE & COMPREHENSIVE TREATMENT PLAN
NRNP 6541: Primary Care of Children & Adolescents
Patient Name Date of Visit Provider / Course
Courtney Graham June 2, 2026 NRNP 6541 — NP Student
Age: 8 years | Sex: Female DOB: 06/02/2018 Pediatric Primary Care Clinic
S — SUBJECTIVE
Chief Complaint (CC): "My ear has been hurting really bad for two days and I have a fever." — per patient and
mother
History of Present Illness (HPI):
Courtney Graham is an 8-year-old female presenting with her mother with a 2-day history of right ear pain and
fever. Mother reports the child began complaining of ear pain 2 days ago, initially mild but progressively
worsening. Temperature at home measured at 38.4°C (101.1°F) with Tylenol given with partial relief. Mother
denies any ear drainage, hearing loss, or recent water exposure. Patient has had 2 prior episodes of AOM (ages
4 and 6), both resolved with antibiotics. No recent URI symptoms noted. No current medications except Tylenol
PRN.
OPQRST Pain Analysis Symptom Characterization
Element Patient Report
Onset 2 days ago, gradual onset
Provocation Worsens when lying flat, swallowing, or moving jaw
Quality Throbbing, pressure sensation; described as "like something pushing inside"
Region/Radiation Right ear; intermittent radiation to right jaw
Severity 6/10 pain scale (parent-proxy rating); child rates 5/10
Timing Constant with intermittent spikes; worse at night
🗺️ PAIN / SYMPTOM MAP
PEDIATRIC PAIN BODY MAP — COURTNEY GRAHAM
ANTERIOR VIEW POSTERIOR VIEW
O O
/|\ /|\
Right Ear →★ | | | |
(Pain ●●●) / \ / \
Pain Location: Right periauricular region
Character: Throbbing / pressure / dull ache
Severity: 6/10 (per parent report)
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, Radiation: Right jaw (intermittent)
Aggravating: Lying flat, swallowing, jaw movement
Relieving: Upright position, analgesics
★ = Primary pain site ● = Intensity scale (3 dots = moderate)
Allergies: NKDA — No Known Drug Allergies
Current Medications: Acetaminophen 325mg PO PRN fever/pain (OTC)
Past Medical History (PMH): AOM × 2 prior episodes (ages 4 and 6); no surgeries; no chronic illnesses
Immunization History: Up to date per parent; PCV13 series completed; annual flu vaccine received October
2025
Family History: Mother: recurrent ear infections as child. Father: HTN. No hearing loss in family.
Social History: Lives at home with both parents and one sibling. Attends 3rd grade. No tobacco smoke
exposure. No daycare.
Review of Systems (ROS):
• Constitutional: Fever (38.6°C), fatigue, mild irritability
• HEENT: Right ear pain ★ (primary complaint), no drainage, mild rhinorrhea, no sore throat
• Respiratory: No cough, no SOB, no wheezing
• GI: Decreased appetite, no nausea/vomiting, no diarrhea
• Neurological: No headache, no dizziness, no hearing changes reported
• Musculoskeletal: No neck stiffness reported
O — OBJECTIVE
Vital Signs Measured at Time of Visit
Vital Sign Patient Value Normal Range (Peds) Status
Temperature 38.6°C (101.5°F) 36.1–37.2°C ⚠ ELEVATED
70–110 bpm (school-
Heart Rate 102 bpm ✓ Normal
age)
Respiratory Rate 22 breaths/min 18–25 breaths/min ✓ Normal
Blood Pressure 108/68 mmHg 90–110/60–74 mmHg ✓ Normal
O₂ Saturation 98% (RA) 95–100% ✓ Normal
Weight 28.5 kg (62.8 lbs) Age-appropriate ✓ Normal
Height 132 cm (52 in) Age-appropriate ✓ Normal
BMI 16.4 kg/m² 5th–85th percentile ✓ Normal
Physical Examination Findings
System Findings Clinical Significance
Right TM: bulging, erythematous, ↓ light
Consistent with Right AOM Left ear WNL
HEENT reflex, no perforation Left TM: intact,
No strep pharyngitis signs
pearly gray, cone of light present Nares:
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NRNP 6541: Primary Care of Children & Adolescents
Patient Name Date of Visit Provider / Course
Courtney Graham June 2, 2026 NRNP 6541 — NP Student
Age: 8 years | Sex: Female DOB: 06/02/2018 Pediatric Primary Care Clinic
S — SUBJECTIVE
Chief Complaint (CC): "My ear has been hurting really bad for two days and I have a fever." — per patient and
mother
History of Present Illness (HPI):
Courtney Graham is an 8-year-old female presenting with her mother with a 2-day history of right ear pain and
fever. Mother reports the child began complaining of ear pain 2 days ago, initially mild but progressively
worsening. Temperature at home measured at 38.4°C (101.1°F) with Tylenol given with partial relief. Mother
denies any ear drainage, hearing loss, or recent water exposure. Patient has had 2 prior episodes of AOM (ages
4 and 6), both resolved with antibiotics. No recent URI symptoms noted. No current medications except Tylenol
PRN.
OPQRST Pain Analysis Symptom Characterization
Element Patient Report
Onset 2 days ago, gradual onset
Provocation Worsens when lying flat, swallowing, or moving jaw
Quality Throbbing, pressure sensation; described as "like something pushing inside"
Region/Radiation Right ear; intermittent radiation to right jaw
Severity 6/10 pain scale (parent-proxy rating); child rates 5/10
Timing Constant with intermittent spikes; worse at night
🗺️ PAIN / SYMPTOM MAP
PEDIATRIC PAIN BODY MAP — COURTNEY GRAHAM
ANTERIOR VIEW POSTERIOR VIEW
O O
/|\ /|\
Right Ear →★ | | | |
(Pain ●●●) / \ / \
Pain Location: Right periauricular region
Character: Throbbing / pressure / dull ache
Severity: 6/10 (per parent report)
Page
, Radiation: Right jaw (intermittent)
Aggravating: Lying flat, swallowing, jaw movement
Relieving: Upright position, analgesics
★ = Primary pain site ● = Intensity scale (3 dots = moderate)
Allergies: NKDA — No Known Drug Allergies
Current Medications: Acetaminophen 325mg PO PRN fever/pain (OTC)
Past Medical History (PMH): AOM × 2 prior episodes (ages 4 and 6); no surgeries; no chronic illnesses
Immunization History: Up to date per parent; PCV13 series completed; annual flu vaccine received October
2025
Family History: Mother: recurrent ear infections as child. Father: HTN. No hearing loss in family.
Social History: Lives at home with both parents and one sibling. Attends 3rd grade. No tobacco smoke
exposure. No daycare.
Review of Systems (ROS):
• Constitutional: Fever (38.6°C), fatigue, mild irritability
• HEENT: Right ear pain ★ (primary complaint), no drainage, mild rhinorrhea, no sore throat
• Respiratory: No cough, no SOB, no wheezing
• GI: Decreased appetite, no nausea/vomiting, no diarrhea
• Neurological: No headache, no dizziness, no hearing changes reported
• Musculoskeletal: No neck stiffness reported
O — OBJECTIVE
Vital Signs Measured at Time of Visit
Vital Sign Patient Value Normal Range (Peds) Status
Temperature 38.6°C (101.5°F) 36.1–37.2°C ⚠ ELEVATED
70–110 bpm (school-
Heart Rate 102 bpm ✓ Normal
age)
Respiratory Rate 22 breaths/min 18–25 breaths/min ✓ Normal
Blood Pressure 108/68 mmHg 90–110/60–74 mmHg ✓ Normal
O₂ Saturation 98% (RA) 95–100% ✓ Normal
Weight 28.5 kg (62.8 lbs) Age-appropriate ✓ Normal
Height 132 cm (52 in) Age-appropriate ✓ Normal
BMI 16.4 kg/m² 5th–85th percentile ✓ Normal
Physical Examination Findings
System Findings Clinical Significance
Right TM: bulging, erythematous, ↓ light
Consistent with Right AOM Left ear WNL
HEENT reflex, no perforation Left TM: intact,
No strep pharyngitis signs
pearly gray, cone of light present Nares:
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