SOAP Note for Ear Infection
Subjective
Chief Complaint:
- Document ear pain (otalgia), fever, irritability, or hearing changes 1
- Onset timing: acute (less than 48 hours) versus subacute symptoms 1
- Recent upper respiratory infection or cold symptoms 1
- Previous episodes of ear infections and treatment history 1
- Allergy history: specifically ask about penicillin allergy and type of reaction (Type I hypersensitivity versus other) 1
- Current medications, particularly antibiotics taken in the previous 30 days 1
- Associated symptoms: purulent conjunctivitis (suggests H. influenzae), drainage from ear canal 1
Objective
Physical Examination:
- Temperature and vital signs 1
- Otoscopic examination is mandatory - document specific findings: 1
- Remove obstructing cerumen if visualization is inadequate - refer to ENT if unable to visualize 1
- Examine external auditory canal for signs of otitis externa versus otitis media 1
- Assess for tympanostomy tubes if present 1
Assessment
Diagnosis Classification:
Acute Otitis Media (AOM): Requires all three criteria 1:
- Acute onset of symptoms (less than 48 hours)
- Presence of middle ear effusion (documented by bulging TM, limited mobility, or otorrhea)
- Signs of middle ear inflammation (distinct erythema of TM or otalgia)
Severity Stratification 1:
- Severe: Temperature ≥39°C (102.2°F) and/or moderate-to-severe otalgia
- Non-severe: Temperature <39°C and mild otalgia
Age-Based Risk Assessment 1:
- High risk: Children under 2 years
- Lower risk: Children 2 years and older
Plan
Pain Management (ALWAYS address first) 1:
- Acetaminophen or ibuprofen for all patients regardless of antibiotic decision 1
- Pain management is mandatory during first 24 hours 1
Antibiotic Decision Algorithm:
OBSERVATION OPTION (48-72 hours) is appropriate for: 1
- Children 6 months to 2 years: non-severe illness AND uncertain diagnosis
- Children ≥2 years: non-severe illness OR uncertain diagnosis
- Requires assured follow-up within 48-72 hours 1
IMMEDIATE ANTIBIOTIC TREATMENT indicated for: 1
- Children <6 months (all cases)
- Severe illness (any age)
- Bilateral AOM in children 6-23 months
- AOM with otorrhea
- Certain diagnosis with moderate-to-severe symptoms
First-Line Antibiotic Choice:
For patients WITHOUT penicillin allergy: 1, 2
- Amoxicillin 80-90 mg/kg/day divided twice daily 1
- Duration: 10 days for children <2 years; 5-7 days for children ≥2 years 1
If amoxicillin taken in previous 30 days OR concurrent purulent conjunctivitis: 1
- Amoxicillin-clavulanate 90 mg/kg/day of amoxicillin component (14:1 ratio) divided twice daily 1
For penicillin-allergic patients (non-Type I hypersensitivity): 1
- Cefdinir 14 mg/kg/day in 1-2 doses 1
- Cefuroxime 30 mg/kg/day in 2 divided doses 1
- Cefpodoxime 10 mg/kg/day in 2 divided doses 1
- These second/third-generation cephalosporins have negligible cross-reactivity with penicillin 1
For Type I penicillin allergy (anaphylaxis, urticaria): 1
- Azithromycin 10 mg/kg day 1, then 5 mg/kg days 2-5 3
- Note: Less effective against resistant S. pneumoniae 3
Treatment Failure Protocol (no improvement at 48-72 hours): 1
If initially observed without antibiotics: 1
- Start amoxicillin 80-90 mg/kg/day 1
If initially treated with amoxicillin: 1
- Switch to amoxicillin-clavulanate 90 mg/kg/day 1
If second-line treatment fails: 1
Special Circumstances:
Patients with tympanostomy tubes and drainage: 1
- Topical antibiotic drops ALONE (ofloxacin or ciprofloxacin-dexamethasone) twice daily for up to 10 days 1
- Oral antibiotics unnecessary unless child is systemically ill 1
- Superior cure rates (77-96%) versus oral antibiotics (30-67%) 1
Follow-Up:
- Reassess at 48-72 hours if symptoms persist or worsen 1
- No routine follow-up needed if symptoms resolve 1
- Consider ENT referral for: recurrent AOM (≥3 episodes in 6 months), persistent effusion >3 months, hearing loss, or treatment failures 1