Paper details
Assignment 2: Episodic Visit: HEENT Focused Note
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.
Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When yousubmit your Focused Notes, you should include the complete Focused Note as a Word document and
pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused
Notes using SAFE ASSIGN.
Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will
deduct points per the Walden Late Policies.
To prepare:
Use the Episodic/Focus Note Template found in the Learning Resources for this week to complete this
assignment.
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: patient with left foot diabetic wound and fever .
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?
Note: Your Focused Note Assignment must be signed by Day 7 of Week 3.
By Day 7
Submit your Episodic/Focused Note Assignment.
please write a soap note for the patent:
Patient Information:
Patient: Daniel, Richard 41 years old, Caucasian Male
Subjective
Chief complaint: A 40 years Caucasian male presents in the clinic with a complaint of a painful rash on her
left upper chest and left upper back for three days.
History of Present Illness: The patient is a 40 years old Caucasian male who develops a sudden onset of
painful rashes. he complains of pressure like pain on the left chest and left-back 8/10 at the moment. he
has been experiencing pain throughout the day for the past five days. The chest pain is intense, localized,
constant, worsening with movement, and relieve with an analgesic. The patient is taking Percocet 10/325
mg two tablets by mouth twice a day, which was initially prescribed after the neck surgery couple of years
ago. The last dose of analgesic was taken this morning with a small effect.
Current Medications:
Cymbalta 20 mg er daily, Trazodone 50 mg at bedtime,
Percocet 10/325 mg 1-2 tablets oral twice a day as needed.
Allergies: no known allergies
Past Medical History: Anxiety since 2014, the last anxiety attack was three years ago and was relieved with
Lorazepam 1 mg oral twice a daily as needed for a month. She has not been on lorazepam since then.
Hyperlipidemia diagnosed in 2014
Chronic lower back pain since 2013, Head and neck swelling 2011
Surgical history: Lumpectomy and Hysterectomy at the age of 27 years old, Neck effusion 2012
Vaccine: influenza October 2019, Dtap 2014, Variccela first in her childhood, but does not remember the
date. D.R denies childhood illness.
Social History: D. R lives in a house with her wife of 39 years. D.R has three children, two girls, 18 and 10years old respectively, and a 16 years old boy. he is working as a medical assistant in a community family
practice. The patient does not smoke, never use recreational drugs, drinks approximately two to three
glasses of wine per week. The patient likes spending time with her family, loves reading a fiction book, and
the whole family is a big fan of Marvel and D.C. movies. D.R states that he used to walk/run 3-4 miles twice
a week regularly, unfortunately, has not been doing it because of the pandemic. D.R and his family like and
adopt a healthy lifestyle, eat healthy, fewer carbohydrates.
Family History: Father had lung cancer and heart disease and died at the age of 59. Mother has diabetes
and hypertension. No history of genetic disease. Maternal grandmother and grandfather died of old age, no
disease mentioned. Paternal grandfather had diabetes, and chronic renal failure died at the age of 86. The
paternal grandmother died of breast cancer at the age of 72. The patient‘s first daughter is overweight with
no disease. The second daughter is healthy. His 16 years old son wears glasses and has no medical
issues.
Review Of Systems
General: D.R denies weight loss, states he has gain weight in the past couple of days due to anxiety and
unable to control her pain. Denies having fever, no fatigue, and no weakness.
HEENT: denies visual change, no pain, nor redness to eyes. Denies hearing loss, no dizziness
Skin: Rashes to upper left chest and upper left-back
Cardiovascular: pressure-like chest pain, mild palpitation during pain
Respiratory: voiced shortness of breath at times during pain, no coughing
Gastrointestinal: occasionally feeling noxious during pain. No vomiting denies abdominal pain.
Genitourinary: denies burning on urination, no pregnancy. Last menstrual period 06/11/2020.
Neurological: no abnormalities were seen. D.R has the normal sensation to pain upon light touch, normal
proprioception, normal cranial nerves from 2-12, DTRs normal in upper and lower extremities. No
pathologic reflexes, deep tendon reflexes normal to upper and lower extremities. No pathologic reflexes
noted.
Musculoskeletal: occasional generalized muscle pain, upper back pain, occasional joint pain.
Hematologic: no anemia, bleeding, or bruising.
Lymphatics: no enlarged nodes. No history of splenectomy.
Psychiatric: the patient has a history of depression or anxiety.
Endocrinologic: denies endocrine disease. The patient denies changes in urinary and bowel habits—no
changes in vision. does not experience intolerance to heat or cold. Appetite remains the same.
Allergies: no known allergies
Objective
BP 108/62, P 96 RR 19, Temp 98.1, Spo2 98% in room air, Weight: 132 lbs., Height: 5’5’’
General: appears anxious, fatigue and scared about her new condition.
Skin: Approximately 6 cm x 5 cm of cutaneous eruptions of erythema and vesicles of a group of 1-3 mm
blisters filled with a serous exudate noted to the left upper chest and left upper back. No drainage noted
over affected areas. The affected areas feel warm and tender upon palpation. No masses noted to chest
and back. No rashes noted to other parts of the body.
Psychiatric: Patient alert and oriented X4, Memory intact, good judgment and insight, feeling anxious a little
upset upon assessment; with normal affect.
Cardiovascular: Heart sound tachycardic, audible and regular. S1 and S2 distinct, no abnormal heart sound
noted upon auscultation, No generalized cyanosis noted, no clubbing noted, negative for bilateral edema
noted.
Respiratory: breathing even and slightly laboured. Able to relax after the explanation of the condition and
reassurance regarding prognostic and treatment measures.
Diagnostic results: The diagnosis of herpes zoster is based on the history and physical of the patient. The
diagnosis is also based on the characteristic of the rashes, the location, the appearance associated with
localized pain. Other diagnostic can include electrocardiograms to ruled out cardiac diseases such as
myocardial infarction, chest radiograph, and abdominal ultrasonography; CBC and differential may not be
crucial; however, it could help find underlying disease. Other testings that are crucial in the clinical setting
are the direct fluorescent antibody testing and the polymerase chain reaction of vesicular fluid, and theTzanck smear of vesicular fluid.
Assessment
Differential Diagnoses
Herpes zoster is an acute, cutaneous viral infection caused by the reactivation of the varicella-zoster virus
that is the cause of varicella. The vesicular lesion of herpes zoster appeared and may last seven to ten
days or more. The disease can often lead to severe postherpetic neuralgia. Different nerves can be
included with the skin rash in the area of its enervation, especially cranial nerves and intercostal nerves
(Cukic., 2016). The patient is presenting with shingles on the left upper chest and left upper back that is
characterized by segmental pain and rash. According to Buttaro et al (2017), the eruption is erythematous
and maculopapular, it is unilateral and affects one dermatome, and the pain can be described as burning,
stabbing, aching or excruciating pain.
Allergic Contact Dermatitis: Related to the presence of localized, erythematous well-demarcated skin
eruption. Allergic Contact dermatitis is a frequent problem and constitutes a challenge to diagnose due to
many potential contact allergens. The most common allergen are nickel, poison Ivy, fragrances,
isothiazolinones (Johansen, & Werfel., 2019). The patient has an increased risk of contracting the condition
by being in contact with the medical and non-medical products at work, such as rubber gloves and
disinfectants. The most effective treatment of allergic contact dermatitis is to identify the allergen and
remove it. The acute phase of acute allergic contact dermatitis is treated with topical or oral corticosteroids
such as lotriderm to the affected area twice a day for a week. An oral antihistamine such as
diphenhydramine 25 mg twice a day for a week can help with pruritus in some cases. In some severe
cases, topical immunomodulators like tacrolimus may be beneficial (Murphy, Hooten, Atwater, et al., 2020).
In addition to cold water and wet soaks help relieve symptoms. Then referral to a dermatologist.
Eczema Herpeticum: is a rare but serious infection that may develop in immunocompromised patients and
can be caused by either herpes simplex virus or varicella-zoster virus infections. The most affected areas
are the trunk, Head, and neck involved. The clinical presentation may include vesiculobullous lesions.
Initiating an empirical with oral acyclovir and antibacterial treatment is crucial to prevent viral dissemination,
which leads to life-threatening complications (Beverido et al., 2017). To diagnose the condition, the use of a
direct fluorescent antibody, and a positive test for herpes simplex virus-1.
Plan, Health Promotion and Disease Prevention
Educating patient about the disease containing the varicella-zoster virus and regarding the risk of
transmission to children or adult who has not to receive the varicella vaccine or previous varicella infection.
Another alternative of care will be to advised patients to consider the varicella vaccine in the future.
Anticipated awareness of prevention of the shingles, according to Shiraki et al. (2017), the lifetime
incidence of herpes zoster recurrence in immunocompetent persons is estimated to be approximately 1-
6%, and it typically occurs many years after the initial episode. In a shingles prevention study, a vaccine
placebo recipient had another episode of herpes zoster within three years of the initial episode—however,
the estimated recurrence to be low but common.
Avoid the use of NSAIDs because of the pandemic
May used lidocaine patch once daily as an alternative pain relieve
Zovirax 1000mg oral twice a day for ten days
Gabapentin 300mg oral daily
Vitamin D 50,000 units weekly
Prednisone 20 mg 4 tabs daily for three days, then three tablets daily for three days, then two tablets oral
for three days, then one tablet oral for three days
Percocet10/325 mg 1-2 tablets oral twice a day as needed
Tylenol 325 mg 1-2 tablets oral every 6 hours as needed
Referral for mammography because of a family history of breast cancer.
Annual Dental referral
Annual Ophthalmology referral
Reflection: Assessing and diagnosing herpes zoster was a great experience. It enables one to learn thatshingles develop in a different part of the body, and patients experienced similar symptoms. This treatment
approach is practical because it covers all patient needs and improves patient health