Case Study: Peds Procedure
MSN-Family Nurse Practitioner Program, Walden University
PRAC: 6565 Synthesis in Advanced Nursing Practice of Patients in Family Care Settings
Practicum
13:57:10 GMT -05:00
, Focused SOAP Note: Peds Procedure
Patient Information:
Branch, 11, WM
S.
CC (chief complaint): nosebleed
HPI: Branch is a 11yo WM presenting to the clinic with his mother 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. She reports that he has had a bloody nose for about 30-45 minutes. He has no history of
nosebleeds. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it
won’t stop. He states that the left side is the side that is bleeding.
Current Medications: none
Allergies: NKDA, no food, environmental or latex allergies.
PMHx: Currently up to date on all immunizations. He received a flu shot last year and will
receive it this year. Denies COVID vaccine currently. Denies past major illnesses, injuries,
surgeries, and hospitalizations.
Soc & Substance Hx: He is currently in the 5th grade at Champion. He is not active in any sports. He
lives at home with working smoke detectors with his parents and is an only child. Denies tobacco,
alcohol, and illicit drug use. He wears his seatbelt in the car and has a strong support system
consisting of his family and friends.
Fam Hx: Mother:
Healthy Father:
Healthy
Pat Gpa: Hypertension, CAD
Pat Gma: DM
Mat Gpa: Lung Cancer (deceased, age 74)
Mat Gma: Hypertension, Hyperlipidemia
Surgical Hx: No prior surgeries.
Mental Hx: Denies concerns of anxiety and/or depression, self-harm practices and/or suicidal or
homicidal ideation.
Violence Hx: Denies concern or issues about safety.
13:57:10 GMT -05:00
MSN-Family Nurse Practitioner Program, Walden University
PRAC: 6565 Synthesis in Advanced Nursing Practice of Patients in Family Care Settings
Practicum
13:57:10 GMT -05:00
, Focused SOAP Note: Peds Procedure
Patient Information:
Branch, 11, WM
S.
CC (chief complaint): nosebleed
HPI: Branch is a 11yo WM presenting to the clinic with his mother 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. She reports that he has had a bloody nose for about 30-45 minutes. He has no history of
nosebleeds. Mom and Branch deny trauma to the nose. He says he just woke up with a nosebleed and it
won’t stop. He states that the left side is the side that is bleeding.
Current Medications: none
Allergies: NKDA, no food, environmental or latex allergies.
PMHx: Currently up to date on all immunizations. He received a flu shot last year and will
receive it this year. Denies COVID vaccine currently. Denies past major illnesses, injuries,
surgeries, and hospitalizations.
Soc & Substance Hx: He is currently in the 5th grade at Champion. He is not active in any sports. He
lives at home with working smoke detectors with his parents and is an only child. Denies tobacco,
alcohol, and illicit drug use. He wears his seatbelt in the car and has a strong support system
consisting of his family and friends.
Fam Hx: Mother:
Healthy Father:
Healthy
Pat Gpa: Hypertension, CAD
Pat Gma: DM
Mat Gpa: Lung Cancer (deceased, age 74)
Mat Gma: Hypertension, Hyperlipidemia
Surgical Hx: No prior surgeries.
Mental Hx: Denies concerns of anxiety and/or depression, self-harm practices and/or suicidal or
homicidal ideation.
Violence Hx: Denies concern or issues about safety.
13:57:10 GMT -05:00
