Posted: June 14th, 2023

Patient is a 55-year-old male who presents with a chief complaint

Assessing, Diagnosing, and Treating Patients With HEENT Conditions
Number of sources: 4
Paper instructions:
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.

Photo Credit: Getty Images/iStockphoto

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.

__________________________-

Subjective

Patient is a 55-year-old male who presents with a chief complaint of right ear pain.
The pain has been present for 3 days and is described as sharp and stabbing.
The pain is worse when the patient yawns or chews.
The patient also reports hearing a ringing in his right ear.
The patient has no other significant medical history.
Objective

On physical examination, the patient’s right ear is red and swollen.
There is no discharge from the ear canal.
The patient’s hearing is decreased in the right ear.
Assessment

The differential diagnosis for this patient includes:
Acute otitis media
External otitis
Serous otitis media
Barotrauma
The most likely diagnosis in this patient is acute otitis media.
Acute otitis media is an infection of the middle ear.
It is most commonly caused by bacteria.
The symptoms of acute otitis media include ear pain, fever, hearing loss, and drainage from the ear.
The diagnosis of acute otitis media is made clinically.
There is no specific test that is required to diagnose acute otitis media.
Plan

The treatment for acute otitis media includes:
Antibiotics
Pain relievers
Antipyretics
The patient should be started on antibiotics as soon as possible.
The antibiotics will help to kill the bacteria that are causing the infection.
The pain relievers will help to relieve the pain in the ear.
The antipyretics will help to reduce the fever.
The patient should be monitored for improvement.
If the patient does not improve within 48 hours, they should be seen by a doctor.
Reflection notes

The most important “aha!” moment from analyzing this case was the importance of early diagnosis and treatment of acute otitis media.
Acute otitis media is a common infection that can cause significant pain and discomfort.
If it is not treated, it can lead to complications such as hearing loss and mastoiditis.
Early diagnosis and treatment with antibiotics can help to prevent these complications.