HEENT Focus Note

Focused Note assignment: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.• Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this assignment…will attach. • 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?***MUST HAVE 3 journals or reliable sources for references.
Comments / Note

SAMPLE SOLUTON

HEENT Focus Note

Patient information

F.B, 27 years, Female, Hispanic

SS

The patient reported finding nodules on her thyroid

HPI

Location: Thyroid

Onset: Discovered this morning

Character: Can be felt, presses on the windpipe

Associated signs and symptoms: States weight loss and increased nervousness, sweating, and shortness of breath.

Timing: All the time

Exacerbating/relieving factors: None noted

Severity: no pain

Current medication:

Multivitamin daily to boost her immunity

Allergies:

The patient is allergic to kale and cabbage, often causing the thyroid gland to swell when consumed. The treatment for the allergy is taking over-the-counter antihistamines to relieve symptoms.

PMHx:

The patient has received all relevant immunizations including Johnsons & Johnsons Covid-19 vaccine for Covid-19 administered this month.

Soc Hx:

The patient is an active volleyball player. She also loves dancing and cycling. She denies smoking but occasionally drinks alcohol.

Fam Hx: There is no notable genetic condition associated with the subjective…