ASSESSING, DIAGNOSING, AND TREATING PATIENTS WITH HEENT CONDITIONS
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.
Case study:
A mother brings in her 14-year-old son, Branch, because he has had a nosebleed. She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop. He has no history of nosebleeds. He has no significant medical history and no known allergies. He is on no medications. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it won’t stop. He tells you that the left side is the side that is bleeding.
Vital signs: BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%
You recognize that simple pressure is not going to stop the nosebleed so you know that you will have to intervene.
