1
SOAP
Preschool Sick Visit – Ear Pain
*******
William Paterson University
NUR 6130-800: Advanced Practice III
Professor *****
January 29th, 2025
, 2
Date of encounter: January 31st, 2025
Time: 13:30
Source of Information: Patient, Maya Parker, and biological father, Tim Parker
Reason for Visit: Sick Visit
Name: Maya Parker
Age: 4 years old
DOB: 01/05/2021
Sex: Female
Ethnicity: Black
Primary Language: English
SUBJECTIVE:
CC: “I’m a little worried about my daughter’s ear pain. It’s been bothering her since yesterday.”
HPI: Maya Parker is brought into the clinic by her father, Tim Parker, for a sick visit. Dad is the
primary source of history. Dad reports that Maya is complaining of constant right ear pain that
started yesterday. He notices Maya is pulling on her ear and hasn’t stopped. According to
FACES pain rating scale Maya rates her pain as a “4 – hurts little more.” He states Maya’s ear is
really bothering her, making her cranky, and affecting her sleep. Maya states she’s tired. He
denies trying pain relieving treatment or medications at home. He denies any aggravating factors.
He denies fever, runny or stuffy nose, exposure to other sick kids and secondhand smoke. He
states Maya attends Pre-K and recently started swim lessons and her last swim lesson was 2 days
ago. His wife takes Maya to and from swim lessons, so he doesn’t know if her ears and hair are
dried. Denies loss of appetite.
PMH:
General: Diagnosed with autism spectrum disorder at age 3. Maya takes a bath 3-4 times
a week. More tired than normal during the day. No hospitalizations. Last well visit was a
year ago.
Birth History: Born on January 5th, 2021. Maya was an uncomplicated vaginal birth at
38 weeks. Mom started prenatal vitamins at 9 weeks. No complications during pregnancy
or delivery. Mom received epidural. Maya’s birth weight was 3.17kg.
Surgical History: None.
Allergies: Mild seasonal nasal congestion. Denies allergies to latex and medications.
Medications: Gummy multivitamin every morning. No prescription medications.
Immunizations: Up to date on all immunizations.
Nutrition: Maya was breastfed for the first year then baby-led weaning after 8 months.
As per dad, Maya eats a well-balanced diet with plenty of veggies and good proteins.
Maya drinks only water and some occasional milk. Denies any changes to appetite.
Denies food allergies.
SOAP
Preschool Sick Visit – Ear Pain
*******
William Paterson University
NUR 6130-800: Advanced Practice III
Professor *****
January 29th, 2025
, 2
Date of encounter: January 31st, 2025
Time: 13:30
Source of Information: Patient, Maya Parker, and biological father, Tim Parker
Reason for Visit: Sick Visit
Name: Maya Parker
Age: 4 years old
DOB: 01/05/2021
Sex: Female
Ethnicity: Black
Primary Language: English
SUBJECTIVE:
CC: “I’m a little worried about my daughter’s ear pain. It’s been bothering her since yesterday.”
HPI: Maya Parker is brought into the clinic by her father, Tim Parker, for a sick visit. Dad is the
primary source of history. Dad reports that Maya is complaining of constant right ear pain that
started yesterday. He notices Maya is pulling on her ear and hasn’t stopped. According to
FACES pain rating scale Maya rates her pain as a “4 – hurts little more.” He states Maya’s ear is
really bothering her, making her cranky, and affecting her sleep. Maya states she’s tired. He
denies trying pain relieving treatment or medications at home. He denies any aggravating factors.
He denies fever, runny or stuffy nose, exposure to other sick kids and secondhand smoke. He
states Maya attends Pre-K and recently started swim lessons and her last swim lesson was 2 days
ago. His wife takes Maya to and from swim lessons, so he doesn’t know if her ears and hair are
dried. Denies loss of appetite.
PMH:
General: Diagnosed with autism spectrum disorder at age 3. Maya takes a bath 3-4 times
a week. More tired than normal during the day. No hospitalizations. Last well visit was a
year ago.
Birth History: Born on January 5th, 2021. Maya was an uncomplicated vaginal birth at
38 weeks. Mom started prenatal vitamins at 9 weeks. No complications during pregnancy
or delivery. Mom received epidural. Maya’s birth weight was 3.17kg.
Surgical History: None.
Allergies: Mild seasonal nasal congestion. Denies allergies to latex and medications.
Medications: Gummy multivitamin every morning. No prescription medications.
Immunizations: Up to date on all immunizations.
Nutrition: Maya was breastfed for the first year then baby-led weaning after 8 months.
As per dad, Maya eats a well-balanced diet with plenty of veggies and good proteins.
Maya drinks only water and some occasional milk. Denies any changes to appetite.
Denies food allergies.
