Answer for NRNP 6568 Week 3 Assessing, Diagnosing, and Treating Patients With HEENT Conditions

 

Patient Information:

BR, 11 years old, Male, American white

S.

CC (chief complaint): “Nosebleed”

HPI: BR is an 11-year-old male whose mother brought him to the facility complaining of a nosebleed. The mother reported they had been applying pressure by pinching the nose but was unsuccessful. BR notes he woke up and experienced a nosebleed that would not stop. He described the nosebleed to be from the left nostril. He denied a history of nosebleeds or trauma to the nose.

Current Medications: BR denied current medication use

Allergies: BR denied food, drug, or environmental allergies

PMHx: BR’s immunization record is up-to-date

Soc & Substance Hx: BR is the firstborn in his family. He is a student. His hobbies are drawing and soccer. He is the only child in his family. There is no smoking or alcohol use in the family. He wears a helmet when riding a bicycle. He also wears a seat belt when in the car. Their home has smoke detectors.

Fam Hx: BR’s father has controlled hypertension. His maternal grandmother has hypertension while his paternal grandfather has asthma. His deceased aunt had cervical cancer.

Surgical Hx: BR has no history of surgeries

Mental Hx: BR has no history of mental health problems or treatments

Violence Hx: BR has no violence concerns

Reproductive Hx: Not applicable

ROS:

GENERAL: BR denies fever, weight loss, fatigue, or chills

HEENT: Eyes: BR denies eye drainage, redness, or blurred vision. He denies earing loss, pain, or loss of body balance. He reports a nosebleed since morning that has been unresponsive to pinching. He notes the left nostril is bleeding. There is no sneezing or nasal flaring. There is no sore throat or difficulty swallowing.

SKIN: BR denies skin itchiness or rashes

CARDIOVASCULAR: BR denies chest pain, palpitations, edema, or cyanosis

RESPIRATORY: BR denies cough, shortness of breath, or productive cough

GASTROINTESTINAL: BR denies nausea, vomiting, diarrhea, bloating, or constipation

GENITOURINARY: BR denies urgency, frequency, or dysuria

NEUROLOGICAL: BR denies headaches, dizziness, loss of body coordination, or paresthesia

MUSCULOSKELETAL: BR denies muscle pain, joint stiffness, or swelling

HEMATOLOGIC: BR reports a nosebleed. He denies anemia or easy bruising

LYMPHATICS: BR denies lymphadenopathy

PSYCHIATRIC: BR denies anxiety or a depressed mood

ENDOCRINOLOGIC: BR denies heat or cold intolerance, polyuria, polyphagia, or polydipsia

REPRODUCTIVE: BR denies urethral drainage

ALLERGIES: BR denies food, drug, or environmental allergies

O.

Physical exam:

HEENT: The head is atraumatic. There is no ear drainage, ear pulling, or changes in hearing. The assessment of the eyes reveals no eye drainage, redness, or poor pupillary response to the light. Active bleeding is noted in the anterior left nostril. There are no foreign bodies or signs of nose trauma. The assessment of the right nose and throat are unremarkable.

Respiratory: There is unlabored breathing. There are no flaring, crackles, wheezes, or rhonchi.

Cardiovascular: There are regular heart rhythms. There are no heart murmurs, lower limb edema, or cyanosis.

Diagnostic results: A complete blood count test was unremarkable. Diagnostic investigations were not ordered.

A.

Differential Diagnoses:

Anterior nosebleed: Anterior nosebleed is BR’s primary diagnosis. Anterior nosebleeds are the most common type of nosebleeds. They develop due to factors, including exposure to allergens, environmental dryness, coagulopathies, and use of anticoagulants. A rupture of anterior nose blood vessels causes the nosebleeds. Patients present to the hospital complaining of nosebleeds (Seikaly, 2021; Tabassom & Dahlstrom, 2024). BR’s assessment reveals an anterior left nostril bleed.

Nasal trauma: Nasal trauma is the secondary diagnosis to be considered for BR. Nasal trauma can cause fractures or damage to the blood vessels leading to epistaxis (Navaratnam, 2021). However, the history obtained from the patient and physical assessment findings did not reveal any nasal trauma. As a result, nasal trauma is the least likely diagnosis.

Bleeding disorders: Bleeding disorders are the othe