Epistaxis soap

PACE UNIVERSITY COLLEGE OF HEALTH PROFESSIONS LIENHARD SCHOOL OF NURSING

DEPARTMENT OF GRADUATE STUDIES

NURS 642 SOAP Note

Date: 9/2/2025
Patient’s Name: Sara Thompson
DOB: 1/2/1985

CHIEF COMPLAINT

  • “I've had several nosebleeds from my right nostril over the past week.”

HISTORY OF PRESENT ILLNESS

  • Demographics:

    • 40-year-old Caucasian female

  • Chief Complaint:

    • Recurrent right-sided epistaxis

    • Reports four episodes in the past week

  • Symptoms Description:

    • Episodes resolve spontaneously within 15–20 minutes without intervention

    • Denies pain associated with episodes

  • Recent Medical History:

    • Recently had a sinus infection treated conservatively

    • Has been forcefully blowing her nose since then

  • Denials of Other Symptoms:

    • Denies trauma, anticoagulant use, or bleeding elsewhere

    • Denies fever, chills, gum bleeding, hematuria, headache, dizziness, or vision changes

  • Associated Symptoms:

    • Nasal congestion

    • Frequent nose blowing

    • Mild, resolved sinus pressure

PAST MEDICAL HISTORY

  • Seasonal allergic rhinitis (mild, self-managed)

PAST SURGICAL HISTORY

  • Denies any surgical history

FAMILY HISTORY

  • No family history of bleeding disorders

MEDICATIONS

  • Over-the-Counter Medications:

    • Saline spray: 1 spray in nares daily

    • Loratadine 10mg orally as needed for seasonal allergies

ALLERGIES

  • No known drug or food allergies

  • Seasonal environmental allergies

SOCIAL HISTORY

  • Lifestyle:

    • Non-smoker

    • Consumption of wine: 4oz once a week with dinner

  • Occupation:

    • Teacher

  • Living Situation:

    • Lives with husband and two children

  • Denies recreational drug use

IMMUNIZATIONS

  • Influenza vaccination: October 2024

  • COVID-19 vaccination: October 2024

  • Unsure about childhood immunizations

REVIEW OF SYSTEMS

  • General:

    • Denies fever, chills, weight changes, night sweats, and fatigue

  • Nose:

    • Admits nasal congestion and nasal bleeding (see HPI)

    • Denies pain associated with nasal issues

  • Respiratory:

    • Denies cough, shortness of breath (SOB), or wheezing

  • Cardiovascular:

    • Denies chest pain or palpitations

  • Gastrointestinal (GI):

    • Denies bleeding, nausea, or vomiting

  • Genitourinary (GU):

    • Denies hematuria

  • Skin:

    • Denies easy bruising or petechiae

  • Neurological:

    • Denies headache, dizziness, or weakness

VITALS

  • Blood Pressure:

    • 122/78 mmHg

  • Heart Rate:

    • 76 beats per minute (bpm)

  • Temperature:

    • 98.6°F (37°C)

  • Respiratory Rate:

    • 14 breaths per minute

  • Oxygen Saturation:

    • 98% on room air (RA)

PHYSICAL EXAM

  • General:

    • Healthy-appearing woman, alert and cooperative

    • Alert and oriented ×3 (to person, place, time)

  • Nose/Sinus:

    • Dried blood (approximately 1cm) around right naris

    • 0.5cm clot on anterior septum at Kiesselbach’s plexus; no active bleeding observed

    • Sinuses non-tender

  • Mouth:

    • Oral mucosa moist with no lesions

  • Skin:

    • No bruising, petechiae, or rash found

  • Cardiovascular:

    • Regular rate and rhythm, no murmurs, rubs, or gallops

  • Respiratory:

    • Clear to auscultation bilaterally, no wheezes, rales, or rhonchi

DIAGNOSTIC TESTING

  • None performed in office

ASSESSMENT

  • Working Diagnosis:

    • Anterior epistaxis; likely due to local trauma from nose blowing and mucosal irritation

  • Differential Diagnoses:

    1. Posterior epistaxis

    2. Bleeding disorder (platelet dysfunction, coagulopathy)

    3. Hypertension-related epistaxis

    4. Nasal foreign body or neoplasm

PLAN

  • Recommendations:

    1. Apply topical emollient or saline gel to nasal mucosa

    2. Continue using saline spray, manage allergies, and avoid allergy triggers

    3. Schedule follow-up in 1–2 weeks or sooner if symptoms recur

    4. Consider ENT referral if episodes are recurrent, severe, or if the source remains unclear

PATIENT EDUCATION

  1. First aid: lean forward and pinch nostrils for 10–15 minutes during a nosebleed.

  2. Most epistaxis cases are anterior and self-limited; Kiesselbach’s plexus is the most common site for bleeding.

  3. Avoid local trauma and maintain mucosal moisture; use a humidifier at night.

  4. Avoid nose picking and forceful nose blowing.

  5. Avoid NSAIDs/ASA unless prescribed by a healthcare provider.

SIGNATURE

  • Signed by: Minnie Mouse, RN, FNP Student

  • Institution: Pace University

  • Date: Not specified in this section

REFERENCE

  • Tunkel, D. E., Anne, S., Payne, S. C., Ishman, S. L., Rosenfeld, R. M., Abramson, P. J., Alikhaani, J. D., Benoit, M. M., Bercovitz, R. S., Brown, M. D., Chernobilsky, B., Feldstein, D. A., Hackell, J. M., Holbrook, E. H., Holdsworth, S. M., Lin, K. W., Lind, M. M., Poetker, D. M., Riley, C. A., Schneider, J. S., Seidman, M. D., Vadlamudi, V., Valdez, T. A., Nnacheta, L. C., Monjur, T. M., & Seidman, M. D. (2020). Clinical practice guideline: Nosebleed (epistaxis). Otolaryngology–Head and Neck Surgery, 162(1_suppl), S1–S38. https://doi.org/10.1177/0194599819890327

DIAGNOSTIC REASONING

  • Working Diagnosis Description:

    • Anterior epistaxis is supported by:

    • Visible clot at Kiesselbach’s plexus

    • History of recurrent anterior nosebleeds

    • Likely due to forceful nose blowing

  • Differential Diagnoses:

    • Differential Diagnosis #1: Bleeding disorder

    • Unlikely due to absence of personal/family history of bleeding disorders and no other bleeding signs exhibited

    • Differential Diagnosis #2: Hypertension-related epistaxis

    • Unlikely as blood pressure is normal, and there is no reported history of hypertension

    • Differential Diagnosis #3: Nasal foreign body/neoplasm

    • Unlikely due to the absence of foul odor, mass, or chronic unilateral symptoms.