· 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.
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.
- 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?
- Nosebleeds can be divided into three groups. What are they?
- 90% of nosebleeds fall into which group?
- Name 4 indications for intervention by a provider for a nosebleed.
- 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).
- 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 vasconstrictive 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, the sponge/tampon should be coated in _____________ and left in place for __________ hours.
- 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?
- After the close monitoring, the patient should be kept in observation status for ______ minutes.
- If a sponge/tampon is used, it is not 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 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
• 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.
Focused SOAP Note Template
Initials, Age, Sex, Race
CC (chief complaint): A brief statement identifying why the patient is here, stated in the patient’s own words (for instance “headache,” not “bad headache for 3 days”).
HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form, not a list. If the CC was “headache,” the LOCATES for the HPI might look like the following example:
Onset: 3 days ago
Character: pounding, pressure around the eyes and temples
Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia
Timing: after being on the computer all day at work
Exacerbating/relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better
Severity: 7/10 pain scale
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, i.e., angioedema, anaphylaxis, etc. This will help determine a true reaction as opposed to intolerance).
PMHx: include immunization status (note date of
last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more information is sometimes needed.
Soc & Substance Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question 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.
Surgical Hx: prior surgical procedures
Mental Hx: diagnosis and treatment. Current concerns: Anxiety and/or depression. History of self-harm practices and/or suicidal or homicidal ideation.
Violence Hx: concern or issues about safety (personal, home, community, sexual . . . current & historical)
Reproductive Hx: menstrual history (date of LMP), Pregnant (yes or no), Nursing/lactating (yes or no), contraceptive use (method used), types of intercourse: oral, anal, vaginal, other, any sexual concerns
ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows:
EENT: etc. You should list these in bullet format and document the systems in order from head to toe.
Example of Complete ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough, or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.
GENITOURINARY: Burning on urination. Last menstrual period, MM/DD/YYYY.
NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.
MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.
HEMATOLOGIC: No anemia, bleeding, or bruising.
LYMPHATICS: No enlarged nodes. No history of splenectomy.
PSYCHIATRIC: No history of depression or anxiety.
ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.
REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.
ALLERGIES: No history of asthma, hives, eczema, or rhinitis.
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. Always document in head-to-toe format, i.e., General: Head: EENT: etc.
Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidence and guidelines)
Differential Diagnoses: List a minimum of three 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.
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. Each diagnosis or condition documented in the assessment should be addressed in the plan. The details of the plan should follow an orderly manner.
Include a discussion related to health promotion and disease prevention, taking into consideration patient factors such as age and ethnic group; PMH; and other factors, such as socio-economic and cultural background.
The reflection also is included in this section. Reflect on this case and discuss what you learned. Were there any “aha” moments or connections you made?
You are required to include at least three evidence-based, peer-reviewed journal articles or evidence-based guidelines that relate to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7th edition formatting.
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