COURSE:
PRAC 6531 – Primary Care of Adults Across the Lifespan Practicum
Assignment 2: Episodic Visit; HEENT Focused Note
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/Focused Note Template Form where you will gather patient information and relevant diagnostic and treatment information and reflect on health promotion and disease prevention
By Day 7 of Week 3
Submit your Episodic/Focused Note Assignment.
See the weekly Assignment 2 area for details
SOLUTION
Patient Information
Initials: P.L. Age: 28 Sex: male Race: Asian
S.
CC: “My left ear is painful, and it is producing discharge” He also complains of fever.
HPI: P.L. 28-year-old Asian male, presents in the clinic complaining of pain in his left ear, fever, and discharge. The patient states that the problem started after diving into the lake five days ago. The pain has been increasing and rated as 10/10 (Treviño González, Reyes Suárez & Hernández de León, 2021). The discharge is yellowish, and the left ear is warm. He reports trouble hearing, sleeping and low-grade fever. Despite the pain, the patient denies the use of medication to relieve the pain. P.L denies any past medical condition.
Location: Ear Onset: 5 days ago
Character: redness, ear pain, fever, and hearing loss
Associated signs and symptoms: ear pain, fever, discharge from the ear, and trouble hearing. Timing: Often
Relieving factor: none Severity: 10/10
Current medication: the patient denies the use of medication
Allergies: the patient denies food and environment allergies, but he is allergic to penicillin (skin hives, sob)
PMHx: P.L. reported no medical history of health condition, which made him be hospitalized.
P.L. denies receiving Covid vaccines in 2020 and states that his vaccination is UpToDate. The last vaccine was the Tetanus vaccine in 2021 (Simon & Hempel, 2019). He denied any past medical surgeries. He states that he has been healthy and active before diving into the lake.
Soc Hx: P.L. is an instructor. He is not married but takes care of his mother and younger siblings. He likes skating with friends. Still, the patient denies the use of alcohol and tobacco. He is a strong Christian and attends church every Sunday. He wears a safety belt every time he is……………………………please purchase this assignment for $15 only
