NRNP 6631 WEEK 3 EPISODIC VISIT: HEENT FOCUSED NOTE AYESHIA ESSAY
NRNP 6631 WEEK 3 EPISODIC VISIT: HEENT FOCUSED NOTE AYESHIA ESSAY
Episodic/FocusNote Template
Patient Information:
Initials: K.K Age: 21 years
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Sex: Female Race: White
S.
CC (chief complaint): “Cough and runny nose.”
HPI:
K.K. is a 21-year-old White female who presented to the office with complaints of cough and runny nose. The symptoms began three days ago. She described the cough as persistent and non-productive. The cough and runny nose were associated with sneezing and intermittent headache. The patient reported taking OTC antitussive syrup, but the symptoms had persisted. She rated the headache at 3/10 on the pain scale
Current Medications: OTC Cough syrup and Tylenol to suppress cough and relieve headache.
Allergies: No food or drug allergies.
PMHx: No chronic illnesses. The last influenza shot- was 15 months ago. TT- 8 years ago. No history of surgery.
Soc Hx: K.K. is a college student and lives with her parents. She has three siblings, 29, 25, and 15 years. Her hobbies are swimming and baking. She takes 2-3 glasses of whiskey on weekends and uses recreational marijuana. She denies smoking. She reports attending annual health check-ups, which her parents’ insurance coverage has facilitated. The patient sleeps 8-9 hours daily takes morning runs for about 30 minutes daily to be physically active.
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Fam Hx: Maternal grandmother died from Heart failure at 92 years. The parents are alive and well. The elder brother has asthma.
ROS:
GENERAL: Reports suppressed appetite. Negative for fever, weight changes, or increased fatigue.
HEENT: Head: Positive for headache. Eyes: Denies vision changes, excessive lacrimation, or eye pain. Ears: Denies ear pain, discharge, tinnitus, or hearing loss. Nose: Reports runny nose, non-productive cough, and sneezing. Throat: Reports mild sore throat.
SKIN: Denies discoloration, rashes, or bruises.
CARDIOVASCULAR: Denies edema, palpitations, chest pain, or dyspnea on exertion.
RESPIRATORY: Positive for cough. Denies chest pain, breathing difficulties, wheezing, or sputum
GASTROINTESTINAL: Denies vomiting, abdominal discomfort, altered bowel patterns, or rectal bleeding.
GENITOURINARY: Negative for dysuria, urinary incontinence, penile discharge, urgency, or frequency.
NEUROLOGICAL: Positive for headache. No dizziness, fainting, tingling sensations, or muscle paralysis.
MUSCULOSKELETAL: No joint pain, stiffness, or muscle pain.
HEMATOLOGIC: No bruises or delayed wound healing.
LYMPHATICS: No swollen lymph nodes.
PSYCHIATRIC: Denies anxiety, depression, or mood disorders
ENDOCRINOLOGIC: Denies polydipsia, polyuria, polyphagia, or increased sweating.
ALLERGIES: Denies hay fever or hives.
O.
Physical exam:
Vital signs: BP-110/76; HR-80; Temp-98.4; RR-16b/min; SPO2-99%;
WT- 152 pounds; HT-5’5
General: The patient is a 60-year-old well-nourished White woman. She is alert, well-groomed, and in no acute distress. She maintains eye contact and has clear, coherent speech.
HEENT: Head: Normocephalic and atraumatic; Tenderness to palpation of the frontal and maxillary sinuses. Eyes: Sclera is white; Conjunctiva is pink; PERRLA. Ears: Tympanic membranes are patent, transparent, and shiny. Nose: A red nose with a profuse, dripping nasal discharge; Clear and watery nasal discharge; Glistening and erythematous nasal mucous membranes. Throat: No erythema. Tonsils are +2. No exudates were seen. Mildly enlarged, non-tender cervical lymph node.
Respiratory: Chest rises and falls in unison during respiration; Smooth respirations. Lungs are clear on auscultation bilaterally. Rhonchi present on chest auscultation.
Cardiovascular: No edema or distension of neck veins; S1 and S2 normal on auscultation. No gallop sounds or systolic murmurs were heard.
Diagnostic results: Complete blood count- WNL
A.
Differential Diagnoses
Common Cold: The characteristic symptoms of common cold include rhinorrhea, nasal congestion, and sore or scratchy throat (Lee, 2019). Other clinical features include headache, cough, sneezing, facial and ear pressure, loss of sense of smell and taste, and voice hoarseness (Jaume et al., 2020). Common cold is the primary diagnosis since the patient has a runny nose, intermittent headache, non-productive cough, sneezing, and mild sore throat.
Vasomotor rhinitis: Clinical features include headache, rhinorrhea, nasal congestion, sneezing, postnasal drip, facial pressure, coughing, and throat clearing (Crisci & Ardusso, 2020; Agnihotri & McGrath, 2019). The patient has positive symptoms like runny nose, sneezing, non-productive cough and headache making this a differential diagnosis.
Acute Sinusitis: Acute sinusitis is characterized by facial pain, frontal headache, nasal discharge, nasal blockage, persistent cough, maxillary dental pain, and hyposomia (Patel & Hwang, 2018). It is a differential based on positive findings of rhinorrhea, persistent cough, and headache. However, the patient has no facial pain or tenderness, which is the cardinal symptom of Acute sinusitis (Husain et al., 2018).
P.
Common Cold
Diagnostic studies: Bacterial throat culture or rapid strep testing to evaluate the presence of group A streptococci if oropharyngeal examination suggests streptococcal infection (Pappas, 2018).
Medications: Cetrizine 10 mg PO once daily for 5 days; Tylenol 500 mg PO QID; Phenylephrine nasal 1-3 gtt intranasally every 2-4 hours of 0.125% solution PRN, for 3 days (Jaume et al., 2020).
Health education: Avoiding finger-to-eyes or finger-to-nose contact; Appropriate hand washing; Using nasal tissue to avoid spread by hand-to-hand contact (Pappas, 2018).
Referrals: Referral to a Respiratory physician if symptoms do not improve with treatment
Follow-up: Follow up after two weeks to evaluate progress.
Reflection:
I agree with the preceptor’s diagnosis and treatment plan for this patient. This is because the patient presented with clinical symptoms of common cold, which include nasal dryness or irritation, sore throat or throat irritation, nasal discharge, nasal congestion, sneezing, and headache. I have learned that Common cold is caused by infection by Rhinoviruses. Health promotion for this case should focus on healthy lifestyle practices including taking a healthy diet, regular physical exercises, and limiting alcohol consumption.
References
Agnihotri, N. T., & McGrath, K. G. (2019). Allergic and non-allergic rhinitis. Allergy and asthma proceedings, 40(6), 376–379. https://doi.org/10.2500/aap.2019.40.4251
Crisci, C. D., &Ardusso, L. (2020). A Precision Medicine Approach to Rhinitis Evaluation and Management. Current treatment options in allergy, 7(1), 93–109. https://doi.org/10.1007/s40521-020-00243-1
Husain, S., Amilia, H. H., Rosli, M. N., Zahedi, F. D., Sachlin, I. S., & Development Group Clinical Practice Guidelines Management of Rhinosinusitis in Adolescents & Adults (2018). Management of rhinosinusitis in adults in primary care. Malaysian family physician: The Official Journal of the Academy of Family Physicians of Malaysia, 13(1), 28–33.
Jaume, F., Valls-Mateus, M., & Mullol, J. (2020). Common Cold and Acute Rhinosinusitis: Up-to-Date Management in 2020. Current allergy and asthma reports, 20(7), 28. https://doi.org/10.1007/s11882-020-00917-5
Lee, W. J. (2019). Common Cold and Flu. Vitamin C in Human Health and Disease: Effects, Mechanisms of Action, and New Guidance on Intake, pp. 89–100. https://doi.org/10.1007/978-94-024-1713-5_5
Pappas, D. E. (2018). The Common Cold. Principles and Practice of Pediatric Infectious Diseases, 199–202.e1. https://doi.org/10.1016/B978-0-323-40181-4.00026-8
Patel, Z. M., & Hwang, P. H. (2018). Acute Bacterial Rhinosinusitis. Infections of the Ears, Nose, Throat, and Sinuses, 133–143. https://doi.org/10.1007/978-3-319-74835-1_11
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EPISODIC VISIT: HEENT FOCUSED NOTE
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 Turnitin.
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.
RESOURCES
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
LEARNING RESOURCES
Required Readings
- Fowler, G. C. (2020). Pfenninger and Fowler’s procedures for primary care (4th ed.). Elsevier.
- Section 4: Eyes, Ears, Nose, and Throat
- Chapter 62, “Cerumen Impaction Removal” (pp. 388–392)
- Section 13: Urgent Care
- Chapter 200, “Corneal Abrasions and Removal of Corneal or Conjunctival Foreign Bodies” (pp. 1338–1344)
- Chapter 201, “Slit-Lamp Examination” (pp. 1345–1349)
- Chapter 202, “Auricular Hematoma Evacuation” (pp. 1350–1354)
- Chapter 204, “Removal of Foreign Bodies from the Ear and Nose” (pp. 1359–1364)
- Chapter 205, “Management of Epistaxis (pp. 1365–1371)
- Section 4: Eyes, Ears, Nose, and Throat
Practicum Resources
- HSoft Corporation. (2019). Meditrek: Home.Links to an external site. https://edu.meditrek.com/Default.html
Note: Use this website to log into Meditrek to report your clinical hours and patient encounters. - Walden University Field Experience. (2019a). Field experience: College of NursingLinks to an external site.. https://academicguides.waldenu.edu/fieldexperience/son/home
- Walden University Field Experience. (2019b). Student practicum resources: NP student orientation.Links to an external site. https://academicguides.waldenu.edu/StudentPracticum/NP_StudentOrientation
- Walden University. (2019). MSN nurse practitioner practicum manual.Links to an external site. https://academicguides.waldenu.edu/fieldexperience/son/formsanddocuments
- Document: Episodic/Focus Note Template (Word document)Download Episodic/Focus Note Template (Word document)
Required Media
- SOAP Notes
In this media program, Dr. Nancy Hadley discusses the expectations for developing a SOAP note. (27m)
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?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
BY DAY 7
Submit your Episodic/Focused Note Assignment.
(Note: You will submit two files, your Focused Note Assignment, and a Word document of pdf/images of each page that is initialed and signed by your preceptor by Day 7 of Week 3.)
SUBMISSION INFORMATION
Before submitting your final assignment, you can check your draft for authenticity. To check your draft, access the Turnitin Drafts from the Start Here area.
- To submit your completed assignment, save your Assignment as WK3Assgn2_LastName_Firstinitial
- Then, click on Start Assignment near the top of the page.
- Next, click on Upload File and select Submit Assignment for review.
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Rubric
| Criteria | Ratings | Pts | ||||
|---|---|---|---|---|---|---|
| This criterion is linked to a Learning OutcomeOrganization of Write-up |
|
30 pts | ||||
| This criterion is linked to a Learning OutcomeThoroughness of History |
|
20 pts | ||||
| This criterion is linked to a Learning OutcomeThoroughness of Physical Exam |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeDiagnostic Reasoning |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeTreatment Plan/Patient Education |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and FormattingEnglish writing standards: Correct grammar, mechanics, and proper punctuation. |
|
10 pts | ||||
| This criterion is linked to a Learning OutcomeWritten Expression and FormattingThe assignment follows parenthetical/in-text citations, and at least 3 evidenced based references are listed. |
|
10 pts | ||||
| Total Points: 100 | ||||||
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