William Byrd, RN, FNP Student 5/10/2013, 11:00 12 Y/O Hispanic Female Patient Subjective Chief Complaint: Ive

been having nosebleeds. History of Present Illness: Patient states that she has been having intermittent nosebleeds for about 2 weeks. The nose bleeds occurred 3 times last week and 2 times the week before that. Her last nose bleed was 3 days ago. The patient states that she has had only one nosebleed at nighttime while she was sleeping. The mother states that the nose bleeds have occurred at random times throughout the day without any specific precipitating events. The nosebleeds are not painful. Bleeding is always from the left nostril. The patient denies nose picking. The patient states that when she has the nosebleeds, she does not feel the blood running down the back of her throat and does not taste the blood in her mouth. The mother states that there was a nosebleed after horseplay with the older brother, but cant remember if this was the first of the nosebleeds or not. States that she has been feeling dry and crusty in her nose for the past few weeks. The bleeding is usually stopped within a few minutes and they have never had to seek emergency care for the nose bleeds. Current Health Status Allergies: None Medications: None. Irregularly takes a childrens multivitamin. Immunizations: Up to date. Habits: No alcohol, tobacco, or illicit drug use. Health Maintenance: This child is seen annually in this clinic for her well child exams. Self-Exam: N/A Nutrition: The patient eats well balanced dinners at home and participates in school lunches at school. Exercise: The mother states that she is a typical active girl. She does not participate in any organized sports, but does participate in PE and also plays outdoors with her brother and friends. Relevant Past Medical History General Health: The patient appears to be in good health. Surgeries: None Blood Transfusions: None

Hospitalizations: None Serious Accidents/Injuries/Fractures: None Major Illness: None Limitations of ADLs: None Social History Home living conditions: Lives in a home with single mother and older brother. Occupation: 7th grade student. Economic Resources: Dependent child Military Record: None Religious Concerns: None Patients Explanatory Model: Patient unsure of the cause of her nose bleeds. Family History: Both parents alive with no know health issues. All grandparents are alive. Paternal grandfather has HTN. ROS Relevant Systems General-Denies weight loss, fatigue, appetite change, fever, itch, rash, or other constitutional changes. Cardiovascular-Denies chest pain, SOB, exercise intolerance, palpitations, LOC, fainting. Respiratory-denies cough, sputum, sneezing. Has had problems with seasonal allergies in the past. Objective BP: 110/68 P: 75 RR 20, Temp 98.4, Ht: 59, Wt: 85lbs, BMI 17.2. Physical Exam Constitutional-Appears well nourished and appropriately sized for a 12 year old girl. She is clean and well groomed. Sitting on exam table without signs of distress. Her mother and older brother are present. HEENT-Nasal mucosa pink, septum midline, no sinus tenderness, no nasal tenderness. There is no evidence of a recent nose bleed. TM with good cone of light. Chest-S1S2, RRR heard, not additional heart sounds heard. Clear breath sounds heard in all fields. Assessment

Anterior Nose Bleed-Due to ease of stopping bleeding, unilateral bleeding (Uphold & Graham, 2003). Systemic disease including liver disease, hypertension, bleeding disorders, hereditary hemorrhagic telangiectasia, granulomatous disease (Uphold & Graham, 2003). This was ruled out because the patient does not have any history of these disorders. Her last well child exam was normal. Medications including aspirin, warfarin, antihistimines, intranasal steroids, or diuretics (Uphold & Graham, 2003). Ruled out because the patient is not taking any medications. Plan Pharmacotherepeutics-Use intranasal saline spray to keep nasal mucosa moist. Can also apply small amount of petrolatum ointment to anterior nares to prevent drying (Uphold & Graham, 2003) Diagnostic tests-Patients last CBC, CMP had no abnormalities. At this time, no labs will be drawn. The patient will follow up if bleeding continues and labs will be drawn at that time. Patient education-Advised to keep mucous membranes moist using techniques listed above. Advised to avoid trauma to the nose during play. No Referral Needed Follow up: Patient will follow up in one month if nose bleeds persist. Will keep a log of the bleeding and how long it takes to control bleeding, side blood comes from, and precipitating events.

Rationale-This is likely due to dry mucosal membranes and/or trauma due to horseplay or picking (although denied by the patient). Based on the description, it appears to be an anterior bleed. The saline and Vaseline will help promote membrane moisture and decrease bleeding.

References Uphold, C.R. & Graham, M.V. (2003). Clinical Guidelines in Family Practice. Gainesville, Fl: Barmarrae Books, Inc.