Running head: TODDLER SOAP NOTE 1 Primary Care: Pediatrics Primary Health Care of Family III NUR604 Practicum FOCUSED SOAP NOTE #3 2 SOAP Note Pediatric & Adolescent Medicine Identifying Data:  Date of Visit: June 4, 2019  Patient Name: T.M.  Age: 2 ye

Running head: TODDLER SOAP NOTE 1 Primary Care: Pediatrics Primary Health Care of Family III NUR604 Practicum FOCUSED SOAP NOTE #3 2 SOAP Note Pediatric & Adolescent Medicine Identifying Data:  Date of Visit: June 4, 2019  Patient Name: T.M.  Age: 2 years and 4 months  Sex: Male  Ethnicity: African American  Date of Birth: 2/02/2017  Visit Type: New Patient  SUBJECTIVE DATA:  TM is a 2 years old, male toddler, the mother and aunt have made the visit because they have noticed TM pulling and trying to poke at his Rt ear for 2 days now. The mother is worried as TM seems frustrated and has become irritable, and his ear is showing redness. TM is her first child and she has brought her Aunt who helps her care for TM.  Chief Complaint (CC):  The Mother states “TM keeps pulling and rubbing his Rt ear for almost two days.”  History of Present Illness (HPI):  The mother states that TM had a cold the previous week with a fever of 101.8, but in two days he was better and until yesterday night she noticed that TM was pulling on his Rt ear, and looked distressed, she thought that maybe he had shampoo so she flushed his ear out with warm water, and used a damp cloth to clean the ear cannel. But before she went to bed around 9 PM, she heard TM crying, and when she went to check on him he was awake and puling on his Rt ear, she thinks it may be an ear infection, but is worried even more now as her Aunt told her that sometimes small insects can get lodged in children’s ears. She states that her apartment is clean, and no insects have been seen, but she really wants to find out what is wrong and get it taken care of. The mother states that TM is not as playful, or happy as he usually is, and does not want to be held for too long by her Aunt, or by her. The mother states that she tried to do a visual exam for foreign bodies in TM’s ear with her cellphone’s light but could not see anything unusual. The mother states that TM has not showed any symptoms of being sick again, no coughing, runny nose, fever, vomiting, diarrhea, or loss of appetite. Mother states that TM has not been in contact with any other children, or has been outside playing or swimming, he has only been out with her Aunt grocery shopping or running errands.  OLDCART:  Onset: 2days ago  Location: Rt ear