Most everyone has at some point experienced minor HEENT conditions, such as a head cold or seasonal allergies, and symptoms, such as a runny nose, watery eyes, or a sore throat. While they are relatively minor and short-lived, they nevertheless impair many of the simple pleasures so many enjoy.
HEENT symptoms can represent a wide variety of issues, some of which suggest problems that extend well beyond their temporary impact on life’s simple pleasures. HEENT conditions can result in dangerous respiratory impairment or be symptoms of life-threatening conditions or disease.
For this Assignment, your instructor will assign a case study, which will give you the opportunity to practice assessing, diagnosing, and treating patients with HEENT conditions.
To Prepare:
• Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with conditions of the head, eyes, ears, nose, and throat.
• Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis.
• Identify three to five possible conditions that may be considered in a differential diagnosis for the patient.
• Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis.
• Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions.
The Assignment
Use the Focused SOAP Note Template to address the following:
• Subjective: What details are provided regarding the patient’s personal and medical history?
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
• Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
• Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: Describe your “aha!” moments from analyzing this case
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