The patient is a 55-year-old female HEENT Focused Note

Episodic Visit: HEENT Focused Note
Number of sources: 3
Paper instructions:
As you reflect on the experiences you have had in your practicum journey so far, you have likely recognized the critical importance of communication skills. Whether speaking with other health professionals or educating patients and families, expressing your thoughts in a clear and concise manner can instill confidence and promote optimal outcomes. Written communication requires the same clarity and conciseness. No doubt you have seen extensive written documentation in the clinical setting and how it is relied on to inform and support diagnostic and treatment plans.

This week, you will continue to engage with Meditrek, recording your clinical hours and patient encounters. You will also learn about evaluation and management of HEENT conditions in the reading selections, as well as conduct a patient evaluation of a patient from your practicum experience who has a HEENT condition. Based on diagnostic and treatment options you identify for the patient, you will identify a primary diagnosis, as well as a treatment and management plan.
Learning Objectives
Students will:

Describe clinical hours and patient encounters
Formulate diagnoses for adult patients
Justify adult patient treatment options
Advocate health promotion and patient education strategies across the adult lifespan
Synthesize the assessment and diagnosis of health conditions for a clinical patient

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.

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?

________________________

Subjective

The patient is a 55-year-old female who presents with a chief complaint of a 2-week history of progressive right-sided hearing loss. She reports that the hearing loss is worse in noisy environments and that she has difficulty understanding speech. She denies any other ear symptoms, such as otalgia, otorrhea, or dizziness.

The patient has a past medical history of hypertension, hyperlipidemia, and diabetes mellitus. She is a current smoker and drinks alcohol socially. She takes lisinopril, atorvastatin, and metformin for her medical conditions.

Objective

On physical examination, the patient’s vital signs are within normal limits. Her external auditory canals are clear and her tympanic membranes are intact. There is no otorrhea or erythema. Weber tuning fork lateralizes to the left ear and Rinne test is positive in the right ear.

Assessment

The differential diagnoses for this patient include:

Sensorineural hearing loss
Conductive hearing loss
Mixed hearing loss

The patient’s history of progressive hearing loss, worse in noisy environments, and difficulty understanding speech is consistent with sensorineural hearing loss. However, the patient’s tympanic membranes are intact and there is no otorrhea, which makes conductive hearing loss less likely. The patient’s history of hypertension, hyperlipidemia, and diabetes mellitus increases her risk for sensorineural hearing loss.

The primary diagnosis is sensorineural hearing loss.

Plan

The patient will be referred to an otolaryngologist for further evaluation and treatment. The otolaryngologist may order a hearing test, such as an audiogram, to confirm the diagnosis of sensorineural hearing loss. The otolaryngologist may also recommend treatment options, such as hearing aids or cochlear implant.

The patient will be educated about the importance of hearing conservation. She will be instructed to avoid loud noise exposure and to use earplugs or earmuffs when necessary. She will also be instructed to have her hearing checked regularly.

Reflection notes

In a similar patient evaluation, I would do the following differently:

I would order a hearing test, such as an audiogram, to confirm the diagnosis of sensorineural hearing loss.
I would educate the patient about the importance of hearing conservation.
I would refer the patient to an otolaryngologist for further evaluation and treatment.