SOAP with GP Letter

**Subjective:** Patient presents today with a chief complaint of left-sided ear pain and decreased hearing, as well as a feeling of fullness in the ear. The pain started approximately 3 days ago, is constant, and is located deep within the ear canal. The pain is described as a sharp, throbbing sensation, rated as a 7/10 in severity. The patient reports that the pain is worsened by chewing and lying down. The patient has tried over-the-counter pain relievers (ibuprofen) with minimal relief. **Past Medical History:** * History of childhood ear infections. * Tonsillectomy at age 8. * Seasonal allergies. **Examination:** * Temperature: 37.2°C, Blood Pressure: 120/80 mmHg, Heart Rate: 78 bpm, Oxygen Saturation: 98% on room air. * Patient appears alert and in mild distress due to pain. * Left ear: mild erythema and swelling of the external auditory canal. No discharge noted. * Right ear: normal appearance. * Otoscopy: Left tympanic membrane is slightly erythematous and bulging. Right tympanic membrane is normal. **Assessment:** 1. Acute Otitis Media, Left Ear **Plan:** * Prescribed Amoxicillin 500mg orally twice daily for 7 days. * Instructed patient to use over-the-counter pain relievers as needed. * Advised patient to follow up if symptoms worsen or do not improve within 48 hours. *** Dear Dr. Thomas Kelly, Thank you for referring this patient to my clinic. The patient presented today with a chief complaint of left-sided ear pain and decreased hearing, as well as a feeling of fullness in the ear. The patient reports that the pain started approximately 3 days ago, is constant, and is located deep within the ear canal. The patient has a past medical history of childhood ear infections, tonsillectomy at age 8, and seasonal allergies. On examination, the patient's temperature was 37.2°C, blood pressure was 120/80 mmHg, heart rate was 78 bpm, and oxygen saturation was 98% on room air. Otoscopic examination revealed a slightly erythematous and bulging left tympanic membrane. The right tympanic membrane appeared normal. The plan is to prescribe Amoxicillin 500mg orally twice daily for 7 days, and the patient was advised to use over-the-counter pain relievers as needed. The patient was also advised to follow up if symptoms worsen or do not improve within 48 hours. Sincerely, [Your Name] Otorhinolaryngologist