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Week 5 SOAP NOTE PART 2| COMPLETE SOLUTIONS| NRP 531
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Week 5 SOAP NOTE PART 2| COMPLETE SOLUTIONS| NRP 531
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5 open-ended questions to ask during HPI exam1. Tell me more about the blank moments you’ve had?
Rationale: Getting more information as to if he remembers the incident, if he felt like he
sensed it coming, if he had any other symptoms along with it, etc. which can help to
rule out seizure disorder or migraines.
2. Tell me what you know about high blood pressure and how to prevent it.
Rationale: Hypertension is one of the highest risk factors for TIA and stroke. It is
important for patient to understand what it is, how to prevent it, how to take bloodpressure
at home, etc. Assessment can be made by having patient explain whathe knows, and
patient tends to remember more by explaining it himself rather than being told by a
provider. Also, these questions will help greatly in assessingpatient’s mental status.
3. What have you been doing for the pain in your ear?
Rationale: It is important to assess how patient was managing the pain at home,i.e.,
Taking Tylenol, putting cold pack around it, etc. This can help further assessthe degree of
pain and what can work to ease the pain. Another good question toassess patient’s mental
status and his ability to care for himself at home
4. Do you have any other pain or discomfort other than left ear?
Rationale: This is one of the basic questions to ask in order to find out what otherissues
patient is experiencing besides earache.
5. Tell me one good incident that you can remember about your forgetfulness.
Rationale: This will help to assess 1) patient’s ability to remember the past 2) hisability
(or inability) to resolve the issue 3) cognitive ability to solve the problem onown
Provide a minimum of 3 rationales for the physical exam components performed.
, 1. Cranial nerves – TIA is a transient episode of neurologic dysfunction, and it is
important to know the injury related to the episode and to determine the stage ofthe
event which will guide appropriate treatment
2. Motor response – Degree of seriousness of TIA episode and prevalence of futurestroke
can be determined by what part of the brain was affected by it. Motor responses are
controlled by cranial nerves and knowing the affected part can help with appropriate
treatment and prevention
3. Otoscopy – Diagnosis of otitis externa is depended on 1) symptoms patient is
experiencing and 2) otoscopy of ear canal. Erythema, edema, and purulent drainage
are signs of infection that can be seen with otoscope. Culture is obtained only for
severe cases.
Brief summaries of evidence-based guidelines articles.
1. External Otitis by Laura A. Goguen, MD
External otitis is usually diagnosed by symptoms and signs, which are pain, pruritus, erythema,
edema, possible drainage, and systemic symptoms in severe cases. Mild otitis is with mild
discomfort and pruritus with minimal canal edema and erythema. This is usually treated with
non-antibiotic topical solution that contains glucocorticoid and acidifying agent. Moderate otitis
has moderate pain and pruritus. The ear canal may bepartially occluded if edema and drainage
are present. Moderate degree of edema and erythema are present. This is treated with topical
solution that is acidic, contains an antibiotic, an antiseptic, and a glucocorticoid. Severe otitis
has intense pain, completelyoccluded canal from edema and drainage, fever, periauricular
erythema, and regional lymphadenopathy. This is treated with longer retention of topical
solution that is acidic, contains antibiotic, an antiseptic, a glucocorticoid, along with oral
antibiotic. Acidifying agent should not be used with any stages of otitis if there is a possibility of
not intact skin inside ear canal.
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