Soap Note HEENT Focused Note

Focused Notes are a way to reflect on your practicum experiences and connect the experiences to the learning you gain from your weekly learning resources. Focused Notes, such as the ones required in this practicum course, are often used in clinical settings to document patient care.

For this Assignment, you will work with a patient with a HEENT condition that you examined during the last three weeks, and complete an Episodic/Focus Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention in light of patient factors such as age, ethnic group, past medical history (PMH), socioeconomic status, and cultural background. In this week’s Learning Resources, please refer to the Focused SOAP Note resources for guidance on writing Focused Notes.

To prepare:

Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment.
Select a patient that you examined during the last three weeks that suffered from any HEENT condition. With this patient in mind, address the following in a Focused Note:
Assignment:

Subjective: What details did the patient provide regarding her personal and medical history?
Objective: What observations did you make during the physical assessment?
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management, including alternative therapies? Include pharmacologic and nonpharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.
Reflection notes: What would you do differently in a similar patient evaluation?

WEEK 3 Head, Eyes, Ears, Nose, and Throat Conditions

Complete your clinical log and patient log in MEDITREK

FOCUSED SOAP NOTE # 1 HEENT

You have a focused SOAP note due. This is an acute visit on a patient with a HEENT complaint. NO health maintenance, follow up or med reviews. All SOAP note are required to be signed by your preceptor, no exceptions. You will then have to scan the signed SOAP into a file (When you load your final submission it must be a word document (doc file), make sure you attached the scanned copy (pdf, tift, etc) with the signature as an attachment before submitting. There will be a 20 point deduction for late submission of SOAP notes that are not signed, and returned for a signature.

You are required to use the template posted in class under required reading.

Look at the tips posted in DOC share and especially on how to load the signed pdf and your SOAP at the same time, Soap Note HEENT Focused Note.

MORE INFO

Soap Note HEENT Focused Note

Introduction

The patient, a male in his 50s, presented with acute onset of right-sided weakness and inability to speak. His past medical history included hypertension and recently developed arthritis. He had been using a cane for the last 3 years due to chronic pain in his lower extremity.

S: Pt reports yearly routine physical. No complaints.

The patient reports that he has a yearly routine physical. No complaints. He states that he does not have any vision, hearing or balance issues. He also does not report headaches or dizziness; nausea or vomiting; chest pain or shortness of breath.

O: 1. HEENT: Normocephalic/atraumatic. PERRLA, EOMI, TMs clear. Carotid upstroke brisk, no bruits or JVD. No thyromegaly or lymphadenopathy. Lungs CTA bilaterally. Heart S1, S2 with no MRG. Abdomen soft and nontender. No hernias appreciated.

Normocephalic.
Atraumatic.
PERRLA, EOMI, TMs clear. Carotid upstroke brisk, no bruits or JVD. No thyromegaly or lymphadenopathy. Lungs CTA bilaterally. Heart S1, S2 with no MRG.* Abdomen soft and nontender.* No hernias appreciated

2. Skin: No rashes or lesions

Skin: No rashes or lesions

A. Color ____

B. Texture ____

C. Temperature ____

3. Extremities: Full ROM with no edema or deformity noted

No edema or deformity noted
Joint pain: NONE
Muscle weakness: NONE
Muscle atrophy: NO SIGNIFICANT ATROPHY ON EXAMINATION OF THE LEFT SHOULDER, RIGHT WRIST AND RIGHT THIGH MUSCLES. THERE WAS A DELTOID AND PECTORAL MUSCLE ATROPHY ON THE LEFT SIDE BUT IT WAS NOT DEFINITELY PATHOLOGICALLY SIGNIFICANT AS IT DID NOT IMPEDE EXAMINATION OF THE SHOULDER OR ELBOW JOINT.
Muscle tenderness: NONE FOUND IN YOUR EXTREMITIES (HANDS, FINGERS AND FEET) DURING EXAMINATION TODAY.
Muscle stiffness: NO STIFFNESS WAS NOTED WITH MOVEMENT OF YOUR EXTREMITIES TODAY AS WELL AS WITH AROMATHERAPY TREATMENT TO HELP RELAX YOU AFTER A LONG DAY OF WORKING OUTSIDE IN THE SUNSHINE ALL DAY LONG!

Differential Diagnosis

Describe the etiology of the disease and the treatment for it.
Discuss prognosis.

Conclusion

It is important to note that the differential diagnosis of a patient presenting with recurrent otitis media and recurrent sinusitis is wide and can include many other causes. A patient’s history should always be taken, but it may not always be possible without a physical examination. Moreover, it is not uncommon for patients with only rare conditions to have symptoms that mimic those of other more common disorders like asthma or allergies. The best way to avoid missing an important diagnosis is through careful observation combined with thorough review of systems

Ehomeworker

Soap Note HEENT Focused Note