NRNP 6568 Week 3 Case Study; Focused SOAP Note
- $20.00
Week 3 Case Study: Focused SOAP note
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.
Patient: B.A. 11-year-old Caucasian male
Subjective
CC: Left side of nose is bleeding, and it won’t stop
HPI: Branch is an 11-year-old Caucasian male who was brought to the clinic by his mother Janis with a persistent nosebleed that started 3 hours ago. Branch reports that he woke up with his nose bleeding on the left side. Mother and patient deny trauma to the nose. Mother has been applying pressure to the nose by pinching it, for 5-10 minutes at a time, but the nosebleed will not stop, and she is very concerned. She has not tried ice or any other remedy to stop the bleeding. Patient has no history of nosebleeds but reports his nose has been stuffy the last couple of days. Has no significant medical history, no bleeding or clotting disorders, and no known allergies. Patient denies illicit drug use and takes no medicines. Denies use of NSAIDS. Denies recent Covid infection, or flu. He denies all other symptoms and reports no pain. Mother reports using the heater more since the weather has gotten colder. She usually uses a cool mist humidifier in the house but has not gotten it out of storage yet. The family does have 2 indoor cats but has never had all allergy reactions to them.
Current medications: None
Allergies: No known drug allergies.
Immunizations: Patient is current on all childhood vaccines: Hep B (4), RV (2), DTaP (5), HIB (4), PCV (4), IPV (4), MMR (2), VAR (2), Hep A (2), Men B (1). Influenza and Covid vaccine
+1 booster. He is due for his 1st HPV. His mother wishes to wait on this.
PMH: Unremarkable. No major illness, or childhood diseases. No broken bones, no trauma.
Social history: Patient lives with his mother in an apartment. His parents are divorced. His father lives 15 minutes away in another neighborhood. He spends 2 days a week and every other weekend with his father........ Continue
