Instructions attached

HEENTFocused SOAP Note

HEENT Focused SOAP note

Patient Information:

M.S, 42-year-old white Female

S.

CC: “Left ear pain” for the past two weeks accompanying with fevers.
HPI: 42 y. o., Female patient presenting for evaluation of left mild ear pain that started two weeks ago. Patient reports left ear pain is constant and pressure like and rates it 4 (scale 0-10). Patient denies drainage, throat, head and sinus pain. Patients left sided ear pain is accompanied by fever of 99.5 – 101.2 F, nasal congestion, clear drainage, fatigue. Treatment prior to arrival includes Tylenol 650 Mg PO Q6hrs for pain and fever. 

Allergies: Seasonal

Current Medications:

Omeprazole 40 mg PO daily

Wellbutrin XL 300 mg PO daily

Alprazolam 1 mg PO daily PRN
PMH: GERD, depression, anxiety. Vaccinations up to date, Tdap 10/17
FH: Mother is living, Father is living. No siblings. No history of premature cardiovascular disease in first degree relatives.
SH : Denies tobacco abuse, denies alcohol use; married for 15 years, no kids.

ROS:

General: Reports occasional fevers (99.8-102.3F). Reports fatigue and lack of energy.

Neurological: No headaches, no dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

HEENT:  Eyes:  No visual loss, blurred vision, doubles vision or yellow sclera. Reports left ear pain that started a week ago and reports pain is a 4 (0-10), Nose, Throat: No hearing loss, sneezing, moderate congestion, runny nose, no 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: No burning on urination. Last menstrual period 03/5/2021.

Musculoskeletal:  No muscle, back pain, joint pain or stiffness.

Psychiatric:

History of depression or anxiety.

O.

Vital Signs: Temp 99.6 F, HR 67, RR 17, BP 128/73, O2 Sat 97%

General: Alert, oriented and cooperative.

HEENT: Head is normocephalic and atraumatic. Pupils equally round, 4 mm, reactive to light and accommodation, sclera translucent, conjunctiva pink and moist. Tympanic membranes are pearly gray with no bulging or exudates noted. Nasal mucosa is moist and pink with clear drainage present.

Neck: Easily moveable without resistance, no abnormal adenopathy in the cervical or supraclavicular areas.

Skin: Normal in appearance, texture, and temperature.

Cardiovascular: Regular rate and rhythm S1/S2. No gallop, murmur or other adventitious sounds noted.

Respiratory: Lungs are clear to auscultation and percussion bilaterally.

Gastrointestinal: No tenderness with palpation, Active BS X 4.

Genitourinary: Deferred.

Musculoskeletal: Normal assessment.

Otoscopic exam revealed no abnormal findings, no redness, no budging and no drainage in both ears.

Consultation: Referral was send to an ENT specialist for further work up.

A.

Primary Diagnosis: Common cold secondary to otalgia:

Acute upper respiratory tract infection (URI), also called the common cold, is the most common acute illness in the United States and the industrialized world. Patients typically present with nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever. Symptoms are self-limited, often lasting up to 10 days. Viruses such as rhinovirus are the predominant cause of acute URI; transmission occurs through contact with the nasal secretions and saliva of infected people (Kim.,et al, 2015 ). The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist.

Differential Diagnosis:

Acute Otitis Media:

Acute otitis media (AOM) is an acute, suppurative infectious process marked by the presence of infected middle ear fluid and inflammation of the mucosa lining the middle ear space. The infection is most frequently precipitated by impaired function of the Eustachian tube, resulting in the retention and suppuration of retained secretions. AOM may also be associated with purulent otorrhea if there is a ruptured tympanic membrane. AOM usually responds promptly to antimicrobial therapy.AOM is a complication of eustachian tube dysfunction that occurred during an acute viral upper respiratory tract infection. Bacteria can be isolated from middle ear fluid cultures in 50% to 90% of cases of AOM. Streptococcus pneumoniae, Haemophilus influenzae (nontypable), and Moraxella catarrhalis are the most common organisms.

Otitis Externa:

Acute otitis externa is a common condition involving inflammation of the ear canal. The acute form is caused primarily by bacterial infection, with Pseudomonas aeruginosa and Staphylococcus aureus the most common pathogens. Acute otitis externa presents with the rapid onset of ear canal inflammation, resulting in otalgia, itching, canal edema, canal erythema, and otorrhea, and often occurs following swimming or minor trauma from inappropriate cleaning. Tenderness with movement of the tragus or pinna is a classic finding. Topical antimicrobials or antibiotics such as acetic acid, aminoglycosides, polymyxin B, and quinolones are the treatment of choice in uncomplicated cases. These agents come in preparations with or without topical corticosteroids; the addition of corticosteroids may help resolve symptoms more quickly. However, there is no good evidence that any one antimicrobial or antibiotic preparation is clinically superior to another. The choice of treatment is based on a number of factors, including tympanic membrane status, adverse effect profiles, adherence issues, and cost. Neomycin/polymyxin B/hydrocortisone preparations are a reasonable first-line therapy when the tympanic membrane is intact (Schaefer & Baugh, 2012). Oral antibiotics are reserved for cases in which the infection has spread beyond the ear canal or in patients at risk of a rapidly progressing infection. 

Allergic Rhinitis:

Allergic rhinitis is a common and chronic immunoglobulin E–mediated respiratory illness that can affect quality of life and productivity, as well as exacerbate other conditions such as asthma. Treatment should be based on the patient’s age and severity of symptoms. Patients should be educated about their condition and advised to avoid known allergens. Intranasal corticosteroids are the most effective treatment and should be first-line therapy for persistent symptoms affecting quality of life (Seidman, Gurgel 2015). More severe disease that does not respond to intranasal corticosteroids should be treated with second-line therapies, including antihistamines, decongestants, cromolyn, leukotriene receptor antagonists, and nonpharmacologic therapies such as nasal irrigation.

P.

Plan: Given history and physical exam findings, presentation most consistent with common cold secondary otalgia.  The differential diagnosis includes otitis media, otitis externa, allergic rhinitis however these are less likely given data presented thus far. Advised to use Tylenol/ibuprofen for pain and fevers. Flonase spray Q6hrs PRN and any OTC decongestants. I agree with my preceptor, there were not enough diagnostic evidence for the patient to be diagnosed with otitis media or otitis externa. Otoscopic assessment did not show any bacterial evidence for antibiotic treatment. Patients fever could be related to her viral infection, so as her ear discomfort. In this case I would educate the patient to return for new or worsening symptoms such as persistent fevers, persistent vomiting, dehydration, altered mental status, severe headaches. Referral to an ENT specialist was sent for further diagnosis of her ear pain. I’ve learned in this case that if you listen to patient long enough, they will tell you exactly what is wrong with them.

References:

Kim SY, Chang YJ, Cho HM, et al. Non-steroidal anti-inflammatory drugs for the common cold. Cochrane Database Syst Rev 2015; :CD006362.

CDC – NCHS – National Center for health statistics. (2021, March 2). https://www.cdc.gov/nchs/index.htm

Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician. 2012 Dec 1;86(11):1055-61. PMID: 23198673.

Seidman MD, Gurgel RK, Lin SY, et al. Clinical practice guideline: allergic rhinitis executive summary. Otolaryngol Head Neck Surg. 2015;152(2):197–206.

Format: APA
Pages: 4 pages ( 1100 words, Double spaced)
Number of sources: 3
Academic level: Master’s
Subject or discipline: Nursing
Title: Writer’s choice
Paper instructions:
Please review attached file and write a SOAP note about diarrhea, pt data can be made up.

Treatment:
Consider stool testing for patients with high risk factors such as prolonged diarrhea, bloody diarrhea, recent antibiotic usage, travel.
Antimotility agents are not indicated for true infectious diarrhea.
Probiotics have been found to be useful and without side effects and diarrhea.
Antibiotics are not generally recommended in adults with acute diarrhea. Wait for cultures if necessary.
Loperamide (Imodium) 2 mg every 4 hours as needed for diarrhea. Avoid if bloody stools or with fevers.
Diphenoxylate (Lomotil) is a another antimotility medication. High risk of side effects. Dose is 4 mg every 6 hours as needed for diarrhea.
Bismuth subsalicylate can also be used sparingly for symptoms.

History of Present Illness
Patient presenting for evaluation of diarrhea, watery stools, abdominal discomfort. Onset of symptoms was 3 days ago. Patient describes a intermittent abdominal pain. Patient has associated symptoms of abdominal cramping, abd discomfort. Patient does not have symptoms of nausea, vomiting, fever, bloody stools, dark stools. Patient reports recent antibiotic usage, recent travel, no recent travel. Patient has no sick contacts. Aggravating symptoms include nothing. Treatment prior to arrival includes Pepto-Bismol, imodium.
Review of Systems: All other systems reviewed and are negative
Physical Exam:
Constitutional: No acute distress
HEENT: Head normocephalic and atraumatic.
CV: Regular rate and rhythm. No murmur.
Respiratory: Lungs clear to auscultation bilaterally
Extremities: Non-tender. No pedal edema.
Back: No tenderness
Neuro: No gross motor deficits
Skin: Normal color. Warm and Dry
Abdomen: soft, nontender, bowel sounds hyperactive, distended, no rebound or guarding
Past Medical History: hypertension, hyperlipidemia, hypothyroidism, COPD
Past Surgical History: hysterectomy
Social History: tobacco use
Family History: no pertinent family history

Medical Decision Making
Patient presenting with diarrhea. No evidence of acute surgical emergency or infection requiring antibiotics.
Diagnostic testing performed: stool testing obtained and pending.
Treatments provided included oral hydration, imodium.
Patient prescribed Lomotil.
Pt was advised on supportive therapies, including increasing dietary fiber, eating smaller meals, refrain from eating copious amounts of irritating foods (fatty foods, milk products, chocolate, and caffeine), maintaining a food diary, advancing fluids as tolerated, refraining from EtOH consumption, decreasing stress, and increasing exercise.
Maintain Fluid Intake: Pedialyte/Gatorade, Juice, Non-caffenated Pop (Sprite, 7-Up). Clear liquid diet, advance as tolerated.
Patient is to followup with primary physician if having continued symptoms. Advised to return to the ER if concern for inability to tolerate PO intake, dehydration, bloody stools, or other concerns.