Practicum - SOAP Note 1

Question

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 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.

Vital signs: BP 110/70 P 84 R 14 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?

What are the three groups of nosebleeds and which is most common?

Name 4 indications for intervention by a provider for a nosebleed. 

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?

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? 

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? 

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

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?

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

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

How long should the patient be kept in observation status?

If a sponge/tampon is used, is it necessary to use antibiotics?

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? 

Name 5 complications of the above procedures. 

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? 

What is the leading cause of nosebleeds in adolescents? 

What CPT code would you use for the above procedure? What is the definition of the code?

Subjective: What details did the patient provide regarding his or her 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 and psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. 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? 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: What was your “aha” moment? What would you do differently in a similar patient evaluation?