Patient Assessment. ENT
Interview responses: No reports of headache, fever, or vision changes. Reports pain as 3/5 on the Wong Baker visual pain scale. Says it feels like someone is stabbing him in his ear. No reports of hearing loss, or ringing in the ears.. No reports of nasal congestion, or discharge; No report of sore throat, difficulty swallowing, wheezing, shortness of breath or cough. No reports of enlarged lymph nodes, chest pain, palpitation, or dizziness. He states the Tylenol Mom gave him helped some with the pain but it still hurts a bit.
Physical exam:
VS
height: 105 cm, weight: 17 kilograms, B/P:102/60, T: 99.9, (given Tylenol one hour before exam) HR: 94 BMP/reg., R: 18, regular, non-labored, oxygen saturation: 99%
General
Cooperative, talkative, appropriate. HEENT: Head normocephalic, Hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Right ear: tympanic membrane intact with light reflex noted. Left ear: tympanic membranes intact, red and bulging. No drainage noted in canal. . Pinna/tragus w/o tenderness bilaterally. Nares patent, unremarkable bilaterally. Pharynx with clear drainage noted, tonsils 2/4 bilaterally. No loose teeth. Neck supple. Lymphadenopathy noted in preauricular and posterior cervical nodes, nontender. Thyroid midline, small, firm. CARDIOPULMONARY: Heart RRR w/o murmur. Lungs are clear to auscultation bilaterally. Respirations are unlabored. Abdomen sl. rounded with active bowel sounds, soft, non-tender, no masses or organomegaly.
Tommy
Interview responses: No reports of headache, fever, or vision changes. Ear was itchy yesterday but now hurts today, Reports pain as 4/5 on the Wong Baker visual pain scale. States it hurts to touch his right ear and his ear hurt when he was eating breakfast. No reports of hearing loss, or ringing in the ears.. No reports of nasal congestion, or discharge; No report of sore throat, difficulty swallowing, wheezing, shortness of breath or cough. No reports of enlarged lymph nodes, chest pain, palpitation, or dizziness. States the Tylenol did not really help. Ear hurts, a lot.
Physical exam:
VS
height: 108 centimeters weight: 18 kilograms, B/P:100/60, T: 98.7 HR: 94 BPM/reg., R: 18, regular, non-labored, SpO2: 99%
General
Cooperative, talkative, appropriate. HEENT: Head normocephalic, Hair thick and distributed throughout entire scalp. Conjunctiva clear, non-icteric, PERRLA, EOM’s intact. Left ear: tympanic membrane intact with light reflex noted. Pinna/tragus w/o tenderness. No drainage noted in canal. Right ear: reports pain on palpation of tragus and with pinna traction. Otoscopic exam shows an erythematous, edematous canal with debris noted. The canal edema prevents visualization of the tympanic membrane. Nares patent, unremarkable bilaterally. Pharynx without drainage, tonsils 2/4 bilaterally. No loose teeth. Neck supple. Cervical lymph without lymphadenopathy, tenderness reported when palpating the right pre and post auricular nodes. Thyroid midline, small, firm. CARDIOPULMONARY: Heart RRR w/o murmur. Lungs are clear to auscultation bilaterally. Respirations are unlabored. Abdomen sl. rounded with active bowel sounds, soft, non-tender, no masses or organomegaly.
Mary
On further questioning Mary reports new onset fatigue and chills. No reports of headache or vision changes. She thought she was just tired from being woken up by her sick kids but now really feels bad. She has not checked her temperature. Reports pain of 4/5 when swallowing. States it feels like something sharp is in her throat when she swallows. States she has not been hoarse or had a cough. No reports of nasal congestion, or discharge No report of wheezing or shortness of breath. No reports of chest pain, palpitation, dizziness or enlarged lymph nodes. No reports of heartburn, or indigestion.
Physical exam:
VS
height: 64 inches weight 149 pounds BP 128/72, Temp 101.2, P 100, regular and R: 14.
General
Alert, oriented and cooperative. HEENT: head normocephalic. Hair thick and distribution throughout scalp. Eyes without exudate, sclera clear. Contact lenses noted. Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate.
Oropharynx moist with erythema with white exudate noted. Tonsils 3/4 bilaterally. Teeth in good repair, no cavities noted. Neck supple. Anterior cervical lymph tender to palpation. No lymphadenopathy. Thyroid midline, small and firm without palpable masses. Cardiopulmonary: Heart S1 and s2 noted, no murmurs, noted. Lungs clear to auscultation bilaterally. Respirations unlabored. Abdomen soft, nontender, bowel sounds auscultated in all four quadrants fields. No organomegaly noted.
Given the exam findings you decide to perform a rapid strep test, the results are positive.
Discussion Part Two
List the primary diagnosis with ICD 10 code. Include your rationale for choosing the primary diagnosis. The diagnostic rationale in the assessment section should include your patients’ symptoms, exam findings and the interpretation of all presented lab findings. Include one evidence-based journal article or clinical guideline that supports your rationale for each patient. Develop a complete evidence-based treatment (EBP) plan for each patient that includes medications, any additional diagnostic tests, patient education, possible referrals, and a plan for follow up with you, the PCP. Each step of the plan must include an intext citation to an approved reference as listed on the Reference Guidelines document. The guidelines for SOAP note documentation is located under Course Resources and can assist you in writing this post and your SOAP note.
