EENT exam - ENT shadow health homework assignments PDF

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ENT shadow health homework assignments ...

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S.O.A.P. Note Template

CASE ID# ________________EENT exam

____________ Subjective Objective Assessment (diagnosis [primary and differential diagnosis]) Plan (treatment, education, and follow up plan)

Chief Complain t

What brought you here today…(eg. headache)

Sinus pressure, headaches, congestion and mild ear pain

Chronological order of events, state of health before onset of CC, must include OLDCARTS in paragraph form Onset 2 weeks Location

History of Present Illness

sinus pressure in forehead, mid face, congestion and headaches

Duration 2 weeks Character Pt complains of headache and pain and pressure in her forehead and mid face area. She reports that she can smell a odor in her nose. Pt reports mild night time coughing and denies any difficulty breathing. Aggravating/associated Headache intensities when coughing at night. She also reports congestion and pressure in her sinus. pt factors denies fever, chills, or night sweats. She does have mild ear pain/pressure when swallowing. She has been taking Tylenol for headaches and Sudafed but with minimal improvement. Pt reports she gets sinus Relieving factors infections frequently about three in the past six months. Her last dose of antibiotics was three months ago. She had a recent nasal polyps removal five years ago but feels like they are back. Pt’s ENT had her on Temporal factors – other steroid shots every 6 months. She does have seasonal allergies but is manageable. things going on Severity

Past Medical History

Adult Illnesses, childhood illnesses, immunizations, surgeries, allergies, current medications

nasal polyps removal seasonal allergies Sinus infections Headaches ear pain Medications: Tylenol, Sudafed

Family History

Personal/ Social History

Include Parents, siblings; N/A grandparents if applicable/known, cause of death, age, pertinent medical illnesses

Education, marital status, occupation, alcohol/drug use, smoking status, sexual history if relevant, exercise, nutrition, religious preference if known

N/A

General: positive for sinus pressure and pain upon palpitation, fatigue. Negative for fever, chills sweats Hair, Skin, & Nails: Intact Head: Headache exasperated by coughing

Neck:

Positive for enlarge tonsils, negative for sore throat, difficulty swallowing,

Eyes: Negative for visual changes, negative for drainage Ears: Positive for ear pain, scarring from old infections. Negative for hearing loss, vertigo for tinnitus Nose:

Review of Systems

positive for nasal congestion, drainage, foul odor

Mouth & Throat: positive for purulent drainage, negative for dryness or hoarseness Cardiovascular: Negative for chest pain, edema, orthopnea Respiratory: Positive for night time cough, denies wheezing, hemoptysis, dyspnea, pneumonia Breasts:

Negative for lumps, lesions, or bumps

Gastrointestinal: Negative for abdominal distention, pain, nausea, vomiting, consitpation, diarrhea, hepatitis, ulcer Musculoskeletal: Negative for muscle weakness, pain, edema, erythema, arthritis Peripheral: Negative for welling or stiffness, fracture or limited ROM Neurological: Negative for dizziness, weakness, numbness or tingling Psychiatric: Negative for recent mood changes, denies SI/HI, positive for fatigue related to CHF

Vital signs: General Appearance: Well-developed white female, mildly ill appearance, no acute respiratory distress Head normcephalic, positive for sinus tenderness. Eyes: conductive are pink, no drainage or jaundice. PERRLA Ears: canals with mild cerumen, tympanic membrane are perky gray and w/o erythema. Positive HEENT: for ear pain and pressure, no hearing loss, old scarring noted from previous ear infection. Nasopharynx purulent drainage noted . Posterior oropharynx without Neck:

Physical Examinat ion

thyroid is not palpable, lymph nodes are not tender, no carotid bruits trachea is midline

Lymph Nodes: no lymphadenopathy noted Chest: breath sounds clear and equal bilaterally w/t adventurous sounds Cardiac:

regular heart rate no murmurs, rubs or clicks present

Abdomen: n/a Genitourinary: n/a Skin:

clear dry and intact

Musculoskeletal: n/a Neurologic: cranial nerves grossly intact Psychiatric: A&O X 4 affect appropriate to situation

Primary diagnosis: Sinus infection

Assessm ent Differential Diagnosis: Chronic sinusitis, headaches

Plan

1.

Augmentin 875/125 one pill QD for 10 days

2.

Sinus wash and OTC decongestant PRN, OTC tylenol for pain PRN

3.

Afrin no more than 3 days and humidifier...