Posted: June 19th, 2022
Episodic SOAP note
Pt P.S, 30 years old, Hispanic, male, complaining of moderate otalgia in the right ear and decreased hearing., slight fever, and headache. History of viral upper respiratory infection 3 weeks ago.
PE: the tympanic membrane is Erythematous, Partial opacification of the tympanic membrane, includes visible fluid (yellowish,) behind an intact bulging tympanic membrane. There is reduced mobility of the tympanic membrane when pneumatic pressure is applied
History of nasal allergies use tobacco and occasionally marijuana. Sexually active but not using any kind of protection for STD. 6 years in this country. Working as a construction worker., living in a small apartment sharing rent. No health insurance. No vaccination history in this country. Paying cash for medical expenses and medications.
UKDA, no surgical history. Father smoker, TN. Mother DM type II, seasonal allergies. 2 sisters, one of them has had asthma since a child the other is healthy.
Dx Acute otitis media (AOM)
Diferencial DX to be included.
Otitis media with effusion
Chronic otitis media
Herpes zoster infección
Obstructive pathologies like nasopharyngeal carcinoma.
Since AOM is unusual in adults, and complications may be significant, it seems prudent to treat all adult patients with antibiotic therapy. amoxicillin 875 mg with clavulanate 125 mg orally twice daily X 7 days
With this patient in mind, address the following in aSOAP Note using the Template provided
· 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? Includepharmacologic(very important to include med, dose,frequencyand duration)andnonpharmacologictreatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan (provide scholarly references for your rationale).
· Reflection notes:What would you do differently (if anything) in a similar patient evaluation?Don’t forget this section-you will lose 10 points if omitted.
· Keep in mind that It needs to be an acute visit on an adult patient with a HEENT complaint
· Follow the SOAP Note template provided – but please be sure to delete the information included which gives you a description of the section and fill in with your findings.
· Keep in mind that this is a graduate-level academic assignment, so please don’t use any unacceptable abbreviations and support your work with current scholarly references (< 5 years old). · At this level in your course, you are required to write at a graduate level using APA format, which includes, but not limited to title page, running head, headers, double spacing, and references. Resources for APA are given under your course resources. Use the following template. Episodic/Focus Note Templat Patient Information: Initials, Age, Sex, Race S. CC (chief complaint) a BRIEF statement identifying why the patient is here in the patient’s own words (e.g., “headache,” NOT "bad headache for 3 days”). HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example: Location: head Onset: 3 days ago Character: pounding, pressure around the eyes and temples Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia Timing: after being on the computer all day at work Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better Severity: 7/10 pain scale Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is (e.g., angioedema, anaphylaxis). This will help determine a true reaction vs intolerance). PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (i.e., previous and current use), any other pertinent data. Always add some health promo question here (e.g., whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system). Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe. Example of Complete ROS: GENERAL: No weight loss, fever, chills, weakness, or fatigue. HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat. SKIN: No rash or itching. CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema. RESPIRATORY: No shortness of breath, cough, or sputum. GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY. NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control. MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness. HEMATOLOGIC: No anemia, bleeding, or bruising. LYMPHATICS: No enlarged nodes. No history of splenectomy. PSYCHIATRIC: No history of depression or anxiety. ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance. No polyuria or polydipsia. ALLERGIES: No history of asthma, hives, eczema, or rhinitis. O. Physical exam: From head to toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head-to-toe format (i.e., General: Head: EENT: etc.). Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines). A . Differential Diagnoses (list a minimum of three differential diagnoses). Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence-based guidelines. P. Includes documentation of diagnostic studies that will be obtained, referrals to other health care providers, therapeutic interventions, education, disposition of the patient and any planned follow up visits. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner. Also included in this section is the reflection. The student should reflect on this case and discuss whether or not they agree with their preceptor’s treatment of the patient and why or why not. What did they learn from this case? What would they do differently? Also include in your reflection, a discussion related to health promotion and disease prevention taking into consideration patient factors (e.g., age, ethnic group), PMH, and other risk factors (e.g., socioeconomic, cultural background). References You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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