Use the following case to complete a focused SOAP note. Incorporate answers to the questions into your SOAP write up.

A mother brings in her 14-year-old son, Branch, to the Urgent Care where you are as a nurse practitioner. He has had a nosebleed. You learn that Branch and his mother live nearby the UC but they do not live near his school. He must take the train to the school and there also is a walk. Her first concern was that he had been attacked during the walk. Branch denied that and reminded them that he has no bruises. The nosebleed began during his sleep and continues this morning so that he could not go to school. The bleeding is bright and a small but steady stream from his right nostril. He has no history of nosebleeds, sinus or allergy problems and uses no nasal sprays. The mother asks how much the cost will be at the UC as she has no health insurance and just lost her Medicaid for them because she received a raise at her job. She says he needs to be seen, even if it is expensive, because they have been applying pressure by pinching it and the nosebleed won’t stop.  You ask for additional information and learn that he has no significant medical history and no known allergies. He is on no medications. Branch does play sports at school, depending on the season. He does not recall any facial injuries at all. He says he just woke up with a nosebleed and it won’t stop. He tells you he is worried he will faint. 

Vital signs:  BP 108/70 P 88 R 18 T 97.8 oral  Pulse ox 99%

You recognize that simple pressure is not going to stop the nosebleed so you know that you will have to intervene. 

Prior to any type of procedure, you have the mother sign an informed consent. What are the three major areas you must discuss when doing any type of procedure?

1. What are the three groups of nosebleeds and which is most common?
2. Name 4 indications for intervention by a provider for a nosebleed.
3. 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. How should the nasal speculum be used and why is it important to use the nasal speculum a certain way?
4. 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?
5. 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? Why it is it important not to use the silver nitrate for over that time frame?
6. After hemostasis is obtained, what are three types of treatment methods that can be used to protect the cauterization site?
7. If that had not stopped the bleeding and you had to make the decision to use a nasal sponge or nasal tampon, what should the sponge/tampon be coated in and how long should it be left in place?
8. After putting in the nasal sponge/tampon, approximately 2 ml of ________ or _______ should be dripped onto the tip to help the sponge expand.
9. After placing the nasal sponge/tampon, the patient should be closely monitored for 3-5 minutes. Why is that?
10. How long should the patient be kept in observation status?
11. If a sponge/tampon is used, is it necessary to use antibiotics?
12. 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?
13. Name 5 complications of the above procedures.
14. After the procedure, you tell Branch and his mother that he can take acetaminophen for any pain/discomfort. Why is it important not to have him take ibuprofen?
15. What is the leading cause of nosebleeds in adolescents?
16. What CPT code would you use for the above procedure? What is the definition of the code?Replies to this email will be posted as a reply to the announcement, 

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.