29 Dec Explain your plan for diagnostics and primary diagnosis

Use the Focused SOAP Note Template to address the following:

 

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 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).

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?

 

 

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 exam 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.

 

 

 

 

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.