Episodic/Focused SOAP Note: Nosebleed Assignment

Episodic/Focused SOAP Note: Nosebleed Assignment

Episodic/Focused SOAP Note: Nosebleed Assignment

Patient Information: B. W. is an 11-year-old Asian male

Subjective:

CC (chief complaint): “I woke up this morning nose bleeding and it won’t stop.”

HPI: B.W is an 11-year-old Asian male who was brought into the emergency unit accompanied by his mother with a chief complaint of nosebleed. The patient claims that he started nose bleeding in his left nares in the morning immediately after waking up and it has not stopped since then. He has been applying pressure by pinching but is not effective. The patient denies a history of blood disorders or trauma to the nose. He also denies having any allergies. No associated symptoms were reported.

Location: left nares

Onset: today, 2 hours ago

Character: constant bleeding, spontaneous onset

Associated signs and symptoms: dryness, but no headache no sneezing, no rhinorrhea, no sneezing

Timing: started after waking up this morning

Exacerbating/ relieving factors: Applied pressure to nose with little or momentary relief.

Severity: 1/10 pain scale mainly due to pinching nose to apply pressure

Current Medications: The patient is not taking any medication at the moment.

Allergies: Reports no known, drug, food, or environmental allergies.

PMHx:The patient denies any history of hospitalization or surgery. Immunization status is up to date, with the last flu shot administered in fall 2021, TDaP booster was in 2019.

Soc Hx: The patient is currently in middle school. He likes playing soccer with his peers, especially at school. He comes from a middle-class family, with both parents working as high school teachers. They live in a safe neighborhood, with no violent cases. Parents always encourage their children to put on seat belts when in the car. Denies any member of the family using tobacco or any other drug of abuse.

Fam Hx:The patient comes from a family of 4, a younger brother who is 6 years, the mother is 32 years and the father is 38 years. and father. Both parents and brother are healthy. Paternal grandmother died from a heart attack with a history of DM and Gout. Paternal grandfather is still alive, but asthmatic. Maternal grandmother died of cancer whereas maternal grandfather is still alive with a history of HTN and diabetes.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

GENERAL: No fever, chills, night sweats, body weakness, or recent changes in body weight.

HEENT: Head: no headache, or signs of head injury. Ears: No discharge, tinnitus, pain, or hearing problems. Eyes: No excessive tearing, blurred vision, redness, or use of corrective lenses. Nose: Reports nose bleed for 2 hours. Denies congestion, running nose, or sinus problems. Throat & Mouth: No bleeding gums, the sore throat, or swallowing problems.

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SKIN: Dry, but with no lesions, pimples, hives, or itchiness.

CARDIOVASCULAR: No palpitations, arrhythmias, elevated heart rate, rubs, murmurs, or gallop.

RESPIRATORY:  No chest pressure, dyspnea, coughing, wheezing, apneic episodes, or congestions.

GASTROINTESTINAL: No hernia, tenderness, nausea, vomiting, changes in bowel movement, constipation, or diarrhea.

GENITOURINARY: No change in the frequency or urgency to urinate. No changes in urine color, or foul smell.

NEUROLOGICAL: No dizziness, loss of consciousness, headache, nausea, or vomiting.

MUSCULOSKELETAL: Displays full range of joint movements. Denies muscle pain or backache, or stiffness.

HEMATOLOGIC: Reports nose bleeding for the past 2 hours. Denies history of blood disorders.

LYMPHATICS: No history of enlarged lymph nodes or splenectomy.

PSYCHIATRIC: No depression, anxiety, or any other psychological disorder.

ENDOCRINOLOGIC: No recent unexpected changes in body weight. Denies history of diabetes or thyroid disorders.

ALLERGIES: No known food, drug, or environmental allergies.

Objective.:

Vital signs:  BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%, Ht; 56.5″, Wt.:78.5 lb.

General: The child looks pale and weak. He is however alert and able to answer questions relevantly.

Skin:Pale and dry. No lesions or hives were noted.

HEENT:Head is atraumatic and normocephalic. Pupils are round, equal, and reactive to light. No erythema or effusion on the tympanic membrane. No discharge or swelling was noted in the ear canals. The neck is supple with anterior cervical lymphadenopathy. The throat is clear with no swelling and exudates. Tonsils are not swollen.

Nose: Active bleeding vessel noted in the left nares.

Cardiovascular:S1S2 present, S3 absent. Regular heart rhythm with no murmurs or gallop.

Respiratory:Breathing sounds clear to auscultation.

GI:Non-distended abdomen, with normal bowel movement sound in all four quadrants.

Diagnostic results: Oropharynx inspection reveals negative results for trauma. No abnormalities were noted. Nasal cavity inspection revealsa 3.5 mm abrasion with active bleeding more on the anterior nares. Other diagnostic tests ordered for further evaluation include complete blood count (CBC),international normalized ratio (INR)/prothrombin time (PT), and activated partial thromboplastin time (aPTT)(Naya Loures et al., 2020). A nasal x-raywas also ordered.

Assessment:

1. Epistaxis ICD-10 Code: R04.0: This is a common bleeding disorder, which can result from various causes. The patient is positive for prolonged bleeding for approximately 2 hours on the left nose (Send et al., 2021). Abrasion was noted in the left nares, with bilateral dryness. The patient is however negative for watery and itchy eyes. However, this is the most probable diagnosis confirmed by theabrasion with active bleeding noted in the anterior left nares.
2. Allergic rhinitis: This is another common cause of nosebleeds among children. Sneezing due to mucosal irritation, rubbing of the nose and corticosteroid therapy are the reasons behind epistaxis among children diagnosed with allergic rhinitis (Schuler IV & Montejo, 2021). The patient displayed symptoms of nose bleed but denied other associated diagnostic factors for this disease such as a history of seasonal allergy, or associated symptoms like fever, running nose, headache, and sore throat among others.
3. Nasal trauma: Most cases of epistaxis among children is normally a result of them picking their nose hence inadvertently causing trauma(Roberts, 2020). Other than evidence of bleeding nose, the diagnosis of this condition also depends on additional symptoms such as ecchymosis, tenderness, edema, crepitation, and deformity, which are all negative in this patient.
4. Foreign body: The presence of foreign bodies in the nares can lead to physical injury to the superficial blood vessels(Send et al., 2021). This can further lead to prolonged bleeding from the injured nose with difficulties to stop. Despite the patient displaying profound nose bleeding with no known possible cause, confirmation of the foreign body through x-ray is needed before concluding this diagnosis.
5. Hemophilia: This is a common blood disorder characterized by low levels of either factor VIII (8) or factor IX (9) making it hard for the blood to clot(Roberts, 2020). It is normally inherited. The patient will display prolonged bleeding, without stopping, just like the patient in the provided case study. However, the diagnosis of this disorder requires confirmatory blood screening and clotting test results.

Plan:

Pharmacological Intervention: Administer oxymetazoline nasal 2-3 actuations in the left nostril (Svider et al., 2018).

Non-pharmacological Interventions: Advise the patient to continuouslypinch the bleeding nose for pressure (Roberts, 2020). Recommend silver nitrate stick and application of petroleum jelly to the affected nares as preventive measures for further bleeding.

Referrals: No referrals are necessary at this point.

Consults: Consult with the pharmacists on the right dosage and appropriate use of oxymetazoline (Svider et al., 2018).

Patient Education: Inform the patient on the importance of sticking to the treatment regimen to promote positive outcomes (Svider et al., 2018). Encourage the patient to use a humidifier at bedtime to promote moistening of the mucosa membrane hence preventing epistaxis from reoccurring.

Follow-up visit: The patient should be advised to report back for further evaluation if the bleed occurs again even after treatment.

Reflection Statement: The provided case study gives a clear example of a child suffering from epistaxis. Given that this condition has numerous causes, a comprehensive patent history is needed in addition to a thorough physical examination of the affected nose, to promote accurate diagnosis(Svider et al., 2018). Consequently, when taking care of children, the clinician needs to acknowledge the legal obligation of the patient’s parents in making decisions concerning their health. As such, they should inform them adequately regarding the patient’s condition and possible treatment approaches.

References

Naya Loures, C., Carneiro de Castro, T., Ricci Lima Luz Matsumoto, G., de Souza Siebert, V., Schmitt de Lacerda, L., de Freitas Miranda, M. V., Soares Tepedino, M., Balsalobre, L., Stamm, A. C., & Macoto Kosugi, E. (2020). Systematic endoscopic assessment of bleeding sites in severe epistaxis: the role of the S-point and the superior epistaxis. Rhinology Journal, 0(0). https://doi.org/10.4193/rhin19.466

Roberts, J. C. (2020). Evaluation of Abnormal Bleeding in Children. Pediatric Annals, 49(1), e36-e42.DOI: 10.3928/19382359-20191215-01

Schuler IV, C. F., & Montejo, J. M. (2021). Allergic rhinitis in children and adolescents. Immunology and Allergy Clinics, 41(4), 613-625.DOI: 10.1016/j.iac.2021.07.010.

Send, T., Bertlich, M., Eichhorn, K. W., Ganschow, R., Schafigh, D., Horlbeck, F., … & Jakob, M. (2021). Etiology, management, and outcome of pediatric epistaxis. Pediatric Emergency Care, 37(9), 466-470.DOI: 10.1097/PEC.0000000000001698

Svider, P., Arianpour, K., & Mutchnick, S. (2018). Management of epistaxis in children and adolescents: avoiding a chaotic approach. Pediatric Clinics, 65(3), 607-621.DOI:10.1016/j.pcl.2018.02.007

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CASE STUDY PEDS/PROCEDURES: week 3
If information is not provided, make up or create the information in order to make your note complete. I should not see “unknown,” “information not given,” or “N/A” in your note! But you can put “none” if documented. For example, allergies -no allergies to medications.
For the SOAP note, you are expected to have an APA formatted title page, page numbers throughout, in-text citations, and references.
1. CASE STUDY for SOAP note : Follow template provided for SOAP note
A mother brings in her 11 year old son, Branch, because he has had a nosebleed. She is concerned about it because they have been applying pressure by pinching it and the nosebleed won’t stop. He has no history of nosebleeds. He has no significant medical history and no known allergies. He is on no medications. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it won’t stop. He tells you that the left side is the side that is bleeding.

Episodic/Focused SOAP Note Template:
Patient Information: B. W. is a 11-year-old Asian male
Subjective:
CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – ” my nose just started bleeding when I woke up this morning.”
HPI: Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (11 year old Asian male). You must include the seven attributes of each principal symptom in paragraph form, not a list. Use the following info to write the HPI.
Location: left nares
Onset: today, 2 hours ago
Character: constant bleeding, spontaneous onset
Associated signs and symptoms: dryness, but no headache, no rhinorrhea, no sneezing
Timing: started after waking up this morning
Exacerbating/ relieving factors: Applied pressure to nose with little or momentary relief.
Severity: 1/10 pain scale mainly due to pinching nose to apply pressure
Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).
PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
Soc Hx: include occupation (student) and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo questions here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.
Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
GENERAL: Example: Denies weakness, fatigue, fever, makaise, chills
HEENT:
SKIN:
CARDIOVASCULAR:
RESPIRATORY:
GASTROINTESTINAL:
GENITOURINARY:
NEUROLOGICAL:
MUSCULOSKELETAL:
HEMATOLOGIC:
LYMPHATICS:
PSYCHIATRIC:
ENDOCRINOLOGIC:
ALLERGIES:
Objective.:
Vital signs: BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%, Ht; Wt:
((Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. ))
General: Child is alert, Ox4, appears pleasant, well-nourished, making eye contact, answers questions relevantly.
Skin:
HEENT:
Cardiovascular:
Respiratory:
GI:
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
CBC-
PT/PTT-
Nasal x-ray-
Assessment:
Differential Diagnoses (list 4 other differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.
1. Epistaxis ICD-10 Code: R04.0
2. Allergic rhinitis
3. Nasal trauma
4. Foreign body
5. Hemophilia
Plan:
Pharmacological Intervention:
Non-pharmacological Interventions:
Referrals:
Consults:
Patient Education:
Follow-up visit if needed:
Reflection Statement:
References
You are required to include at 4 evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostic tests and differentials diagnosis.

2. Please answer the questions in a separate document from the SOAP note and attach.
You recognize that simple pressure is not going to stop the nosebleed so you know that you will not have to intervene.
1. Prior to any type of procedure, you have the mother sign an informed consent for a procedures. What are the three major areas you must discuss when doing any type of procedure?

2. Nosebleeds can be divided into three groups. What are they, describe? local, systemic, idiopathic
3. 90% of nosebleeds fall into which group? local is most common type and anterior, not posterior make up 90% of nosebleeds.

4. Name 4 indications for intervention by a provider for a nosebleed.
5. You place Branch on the exam table at approximately 45 degrees. You drape him appropriately. You have him blow his nose gently to remove clots. You then inspect the right side to familiarize yourself with his anatomy. You then inspect the left side using a nasal speculum. When using the nasal speculum, it is important to use it ______________ (HORIZONTALLY/VERTICALLY).

6. Why is it important to use the nasal speculum a certain way?

7. You note that the bleeding is coming from an area on the septum. You know that the next step is to apply a vasoconstrictive solution to the nose. What are two ways you can deliver the vasoconstrictive solution?

8. You note that the area that is the source of the bleeding is about 3 mm in diameter. You make the decision to use a silver nitrate stick. How long should you apply pressure with the stick?

9. Why it is it important not to use the silver nitrate for over that time frame?

10. After hemostasis is obtained, what are three types of treatment methods that can be used to protect the cauterization site?

11. If that had not stopped the bleeding and you had to make the decision to use a nasal sponge or nasal tampon, the sponge/tampon should be coated in _____________ and left in place for __________ hours.

12. After putting in the nasal sponge/tampon, approximately 2 ml of ________ or _______ should be dripped onto the tip to help the sponge expand.

13. After placing the nasal sponge/tampon, the patient should be closely monitored for 3-5 minutes. Why is that?

14. After the close monitoring, the patient should be kept in observation status for ______ minutes.

15. If a sponge/tampon is used, it is not necessary to use antibiotics.
16. If it is necessary to pack the nose, it may be advisable to give the patient a narcotic or sedative medication (unless a contraindication exists). Why?

17. Name 5 complications of the above procedures.
18. After the procedure, you tell the pt and his mother that he can take acetaminophen for any pain/discomfort. Why is it important not to have him take ibuprofen?
19. What is the leading cause of nosebleeds in adolescents?
20. What CPT code would you use for the above procedure?
21. What is the definition of the above code? **** Use APA style. **** Provide 4-5 scholarly references to complete SOAP and questions.