Please generate a SOAP note for a 2‑year‑old female presenting with three‑day right ear pain and nasal drainage, no fever, vomiting, or diarrhea, who attends daycare and has no drug allergies, and include the appropriate CPT and ICD‑10 codes.

SOAP Note for 2-Year-Old Female with Right Ear Pain and Nasal Drainage

SUBJECTIVE

• Chief Complaint: Right ear pain and nasal drainage × 3 days
• History of Present Illness:
  • 2-year-old female presents with right-sided otalgia and nasal drainage for 3 days
  • Acute onset of symptoms
  • Denies fever, vomiting, or diarrhea
  • Behavioral changes noted ("hasn't been herself")
  • Attends daycare daily (high-risk exposure setting)
• Past Medical History: Non-contributory
• Medications: None
• Allergies: NKDA (no known drug allergies)
• Social History: Daycare attendance

OBJECTIVE

• Vital Signs: [Document temperature, heart rate, respiratory rate, weight]
• General: Alert, appears uncomfortable but not toxic
• HEENT Examination:
  • Right Ear:
    • External auditory canal: [Clear/cerumen present - if present, must be removed for adequate visualization]
    • Tympanic membrane: [Document presence/absence of bulging, erythema, mobility on pneumatic otoscopy, air-fluid level, perforation/otorrhea]
  • Left Ear: [Document findings]
  • Nose: Nasal drainage present, [describe color/consistency]
  • Throat: [Document findings]
• Respiratory: Clear to auscultation bilaterally, no respiratory distress
• Other systems: Within normal limits

ASSESSMENT

Primary Diagnosis: Acute Otitis Media (AOM), right ear - if tympanic membrane shows bulging OR new-onset otorrhea OR distinct erythema with impaired mobility 1

The diagnosis of AOM requires three elements: (1) acute onset of signs/symptoms, (2) presence of middle ear effusion (bulging TM, limited/absent TM mobility, air-fluid level, or otorrhea), and (3) signs of middle ear inflammation (distinct TM erythema or severe otalgia) 1.

Differential considerations:

• Otitis media with effusion (OME) - if middle ear effusion present WITHOUT acute inflammation
• Viral upper respiratory infection with referred otalgia

PLAN

Treatment Decision Algorithm:

For this 2-year-old with AOM:

1. Pain Management (MANDATORY): 1

   • Ibuprofen 10 mg/kg PO every 6-8 hours as needed for pain
   • OR Acetaminophen 15 mg/kg PO every 4-6 hours as needed for pain
   • Pain management is a strong recommendation regardless of antibiotic use

2. Antibiotic Therapy:

Given this patient's age (2 years) and daycare attendance, antibiotic therapy is recommended 1, 2. Children under 2 years with definite AOM should receive antibiotics, particularly with bilateral disease or severe symptoms 1, 3.

First-line antibiotic: 1, 2

• High-dose Amoxicillin 80-90 mg/kg/day divided BID × 10 days
  • Example: If child weighs 12 kg: 1000 mg/day = 500 mg PO BID

Alternative if:

• Amoxicillin use in past 30 days: High-dose Amoxicillin-clavulanate 90 mg/kg/day (of amoxicillin component) divided BID × 10 days 1, 2
• Penicillin allergy: Cefdinir 14 mg/kg/day OR Cefuroxime 30 mg/kg/day divided BID 2

Treatment duration: 10 days for children under 2 years 4

Follow-up:

• Reassess in 48-72 hours if symptoms worsen or fail to improve 1
• If treatment failure: Switch to high-dose amoxicillin-clavulanate OR consider ceftriaxone 50 mg/kg IM × 3 days 2
• Routine follow-up in 2-3 weeks to ensure resolution

Anticipatory Guidance:

• Explained signs of worsening infection (increased pain, fever, lethargy, new symptoms)
• Discussed importance of medication compliance
• Advised to return if symptoms worsen or new symptoms develop
• Discussed prevention: consider pneumococcal vaccination status

Parent Education:

• AOM is bacterial superinfection, commonly following viral URI
• Daycare attendance increases risk of recurrent infections
• Complete full antibiotic course even if symptoms improve

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BILLING CODES

CPT Codes:

• 99213 - Office visit, established patient, low to moderate complexity (15-29 minutes)
  • OR 99214 if extended counseling/coordination required (30-39 minutes)
• 92550 - Tympanometry (if performed)

ICD-10 Codes:

• H66.001 - Acute suppurative otitis media without spontaneous rupture of ear drum, right ear (PRIMARY)
• J00 - Acute nasopharyngitis (common cold) - for nasal drainage
• R51.9 - Headache, unspecified (if applicable for referred pain)

Note: If diagnosis is uncertain or TM visualization inadequate, consider H66.91 (Otitis media, unspecified, right ear) and schedule close follow-up or ENT referral 1, 4.