To Prepare:

· Consider what physical assessments 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

Case study

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 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? 
3. 90% of      nosebleeds fall into which group? 
4. Name 4 indications      for intervention by a provider for a nosebleed. 
5. You place      Branch on the assessment 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 vasconstrictive 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?

Address the following:

Create documentation in the Focused SOAP Note Template about the patient in the case study to which you were assigned.
 

In the Subjective section, provide:
• Chief complaint
• History of present illness (HPI)
• Current medications
• Allergies
• Patient medical history (PMHx)
• Review of systems
 

In the Objective section, provide:
• Physical assessment documentation of systems pertinent to the chief complaint, HPI, and history
• Diagnostic results, including any labs, imaging, or other assessments needed to develop the differential diagnoses
 

In the Assessment section, provide:
• At least three differentials with supporting evidence. Explain what rules each differential in or out and justify your primary diagnosis selection. Include pertinent positives and pertinent negatives for the specific patient case.
 

In the Plan section, provide:
• A detailed treatment plan for the patient that addresses each diagnosis, as applicable. Includes documentation of diagnostic studies that will be obtained, referrals to other healthcare providers, therapeutic interventions, education, disposition of the patient, and any planned follow up visits.
• A discussion related to health promotion and disease prevention taking into consideration patient factors, PMH, and other risk factors.
• Reflections on the case describing insights or lessons learned.
 

Provide at least three evidence-based, peer-reviewed journal articles or evidenced-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care.