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.

Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

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?

 

HEENT Focused Soap Note

The notable HEENT condition I have examined in the last three weeks of practice is ear pain. The encounter involved a sixteen-year-old white boy who presented at the clinic in the early afternoon accompanied by her mother. The purpose of the visit was to get a professional evaluation for his ear pain. This paper provides the subjective and objective assessments I undertook as well as the plans of care involved.

Subjective Assessment

Chief Complaint

            “My right ear hurts.”

History of Present Illness

A sixteen-year-old white boy visited the clinic with a complaint of ear pain. He reported that the problem began about a week ago and had been worsening. He reported that the problem was marked by muffled hearing, plugged-up sensation in the ear, itchiness, and drainage. He reported that the discomfort aggravated with touching the earlobes or changes in temperature and sometimes causing him sleeping challenges. He reported taking acetaminophen the previous night to ease the pain.

Past Medical History – The patient denied having any notable past medical history except seasonal colds.  

Medication – He denied taking prescribed medications.

Social History – He is a student and the second born in a family of three. He reported being part of his school’s swimming team.

Family History – His mother and father were without any diagnosed chronic disorder. His maternal grandmother suffered old age hearing loss in her senior years, while his maternal grandfather suffered cataracts. His paternal grandmother suffered hypertension, while the grandfather suffered age-related vision loss.

Review of Systems

1. General – The patient-reported generally feeling well except for the ear pain.
2. HEENT – He denied head trauma, changes in visual acuity, throat pain, and nasal discharge. He reported right ear pain, muffled hearing, plugged-up sensation in the ear, itchiness, and drainage.
3. Neck – He reported neck pain but denied changes in flexibility.
4. Respiratory – He denied chest pain, changes in ventilation, cough, and wheezing.
5. Cardiovascular – He denied chest pain, palpitations, and hypertension.
6. Musculoskeletal – He denied muscle or joint stiffness or pain.  
7. Neurological – He denied syncope, dizziness, light-headedness, spinning sensation, blurred vision, or slight unusual changes in balance.  
8. Activity – He is a student and a swimmer.

Objective Assessment

1. Vital signs – BP 118/78, HR- 90, T 99 F, BMI 24
2. General – The patient is ill-appearing.
3. HEENT – Assessment of the head revealed normal facial symmetry and absence of trauma.

• An eye exam revealed normal vision fields, absence of drainage and eye discoloration, non-lacerated eyelids, and normal eye movement. 
• Assessment of his nose revealed non-inflamed sinuses, absence of congestion or drainage.
•  Ear canal assessment revealed a lack of cerumen, accumulated mycotic debris, ear canal stenosis, granulation tissue, otorrhea, ear canal, and auricle cellulitis. The examination also revealed auricle and tragus tenderness, edema, and erythema.
• Throat assessment revealed the absence of white patches in the posterior pharynx, thrush, or hoarse voice.

4. Neck – Assessment of the neck revealed lymphadenitis.
5. Lungs – Assessment of the lungs revealed the absence of tachypnea.
6. Chest – Assessment of the chest revealed normal chest expansion and absence of tenderness.
7. Neurological – Neurological assessment revealed normal gait and balance.

Assessment

Differential Diagnosis

1. Otitis externa – This disorder is marked by inflammation of the outer ear, affecting the canal and lobes. The condition is also called swimmer's ear because it results from continued exposure to water, making the ear canal vulnerable to inflammation. Normally, the disorder affects one ear, and the patient presents with some degree of temporary changes in sound perception, ear discharge, itchiness in the ear tube, and ear pain. Physical examination may reveal edema and erythema (Carney, 2018), drainage, accumulated mycotic debris, cellulitis or the ear canal and auricle, granulation tissue, tenderness of the auricle and tragus, and otorrhea. Patients with acute otitis externa are also ill-appearing and present with swollen neck glands. Normally, there is no family history of the disease.

The patient reported being a member of his school’s swimming team. He presented with muffled hearing, plugged-up sensation in the ear, itchiness, and drainage. The physical assessment revealed lack of cerumen, accumulated mycotic debris, ear canal stenosis, granulation tissue, otorrhea, and ear canal and auricle cellulitis, auricle and tragus tenderness, edema, and erythema. The patient also presented with no family history of the disease, making the swimmer's ear the most likely diagnosis.

2. Otitis media – Affected persons mainly present with ear pain, hearing challenges, loss of balance, ear drainage, pulling or tugging at the affected ear (Wilson & Wilson, 2021), unusual irritability, and low-grade fever. Otoscopic assessment may reveal tympanic membrane perforation, immobility of the eardrum, cloudy appearance of the eardrum, bulging of the tympanic membrane, presence of effusion, and middle ear erythema. Tympanometry may reveal changes in sound perception because of effusion due to unusually large reflection of sound from the increased pressure caused by fluid accumulation. This disorder is usually accompanied by common cold manifestations. Worth noting, this patient did not present with tympanic membranes and middle ear involvement or accompanying common cold symptoms, making otitis media an unlikely diagnosis.
3. Atopic dermatitis (ear eczema) – This disorder makes the skin itchy and red, mostly in the area where the ear lobes meet the face. This results from the areas becoming dry and cracking due to soap, shampoo, or water entering and irritating the Eustachian tube. Patients present with clear discharge from the ear, itchiness around or in the ear canal, and ear swelling and redness. Affected persons also present with scaly and dry skin inside the Eustachian tube and around the ear. The absence of skin involvement or the areas where the ear lobes meet the face and behind the ears made this an unlikely diagnosis for the patient.
4. Ear canal trauma – This disorder can result in things that scratch the ear canal or rupture the tympanic membranes, including pencil, fingernail, or cotton swab. The disorder also presents from direct blows to the head or ear from fights, sports injuries, or accidents that may damage the inner ear, dislocate the ossicles, distorted and lumpy cartilage, cauliflower ear, or tear the eardrum. Ear trauma can lead to hearing loss or increase middle ear vulnerability to infections. Notably, this patient does not present with head or ear trauma signs, including swollen ear lobes, perforated eardrum, dislocated ossicles, distorted and lumpy cartilage, cauliflower ear (Toynton, 2018), or lacerations, making ear canal trauma an unlikely diagnosis.

Plan

Diagnostics – The diagnostic approaches employed included otoscopy and tympanometry (Danishyar & Ashurst, 2017).

Treatment – The client received outpatient care and was prescribed hydrocortisone, neomycin, and polymyxin B 3 drops to the affected ear QID (Medina-Blasini, & Sharman, 2020).

Education – The client was educated on the recommended way to administer the otic drops and the importance of treatment compliance. The patient was also educated on ways to prevent ear infections, including not sticking anything into his ear canal, turning his head side to side after getting out of the water, and keeping his ears as dry as possible.

“Is There Anything You Would Do Differently On Your Plan?”

I would not do anything differently because the plan extensively examined his HEENT, developed an adequate differential diagnosis, and provided a suitable treatment approach.