Focused SOAP

CASE STUDY 2: Focused Ear Exam

Martha brings her 11-year-old grandson, James, to your clinic to have his right ear checked. He has complained to her about a mild earache for the past 2 days. His grandmother believes that he feels warm but did not verify this with a thermometer.

James states that the pain was worse while he was falling asleep and that it was harder for him to hear. When you begin basic assessments, you notice that James has a prominent tan. When you ask him how he has been spending his summer, James responds that he has been spending a lot of time in the pool.

Using the Episodic/Focused SOAP Template:· 

Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.· focused soap

Provide evidence from the literature to support diagnostic tests that would be appropriate for your case.·   List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Written Expression and Formatting – Paragraph Development and Organization:

Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate a continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria.

Written Expression and Formatting – English writing standards:

Correct grammar, mechanics, and proper punctuationWritten Expression and Formatting – The paper follows the correct APA format for the title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list.

focused SOAP