SOAP: The Patient’s Differential Diagnosis

Analyze the situation. Amy, a 3-year-old girl, is brought to your office by her mother because she has a fever and complains that her ear hurts. She has no significant medical history. The child is not pleased to be in the provider’s office and has been crying. Her mother explains that she developed a “cold” about three days ago with sniffles. As she cries, she continues to cough and has yellowish nasal discharge.

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.