NRP/543: Management Of Pediatric And Adolescent

Week 3: HEENT Conditions

Which simple pleasures do you most enjoy? Perhaps there is a certain comfort food that always hits the spot. It may be that you enjoy listening to your favorite music—or even singing along. Or perhaps you simply enjoy stopping to smell the flowers. The beauty of a simple pleasure is that while it may not change the course of your day, it can briefly put a smile on your face. But what if your ability to enjoy these simple pleasures was suddenly impaired? Suddenly, minor pleasures would make a significant impact on your life.

Conditions of the head, eyes, ears, nose, and throat (HEENT) can impair many of the activities that put smiles on faces. Hearing, balance, taste, swallowing, speech, and breathing are just some of the functions that can suffer as a result. HEENT issues represent some of the most common reasons that patients visit primary and family care offices. And while the conditions can be relatively minor issues, such as allergies or sinusitis, HEENT issues can also result from injury, infection, or serious disease. 

This week, you practice assessing, diagnosing, and treating patients with HEENT conditions and complete a Knowledge Check on these disorders. You will also reflect on your practice exam results from last week and use them to create a study plan that you will use throughout this course to prepare for the national certification exam. 

Learning Objectives

Students will:

  • Create a study plan for the nurse practitioner national certification examination
  • Evaluate patients with HEENT conditions 
  • Develop differential diagnoses for patients with HEENT conditions 
  • Develop treatment plans for patients with HEENT conditions 
  • Identify key concepts related to HEENT conditions

Assignment 2: Assessing, Diagnosing, and Treating Patients With HEENT Conditions

Most everyone has at some point experienced minor HEENT conditions, such as a head cold or seasonal allergies, and symptoms, such as a runny nose, watery eyes, or a sore throat. While they are relatively minor and short-lived, they nevertheless impair many of the simple pleasures so many enjoy.

HEENT symptoms can represent a wide variety of issues, some of which suggest problems that extend well beyond their temporary impact on life’s simple pleasures. HEENT conditions can result in dangerous respiratory impairment or be symptoms of life-threatening conditions or disease. 

For this Assignment, your instructor will assign a case study, which will give you the opportunity to practice assessing, diagnosing, and treating patients with HEENT conditions.

To Prepare:

  • Review this week’s Learning Resources. Consider how to assess, diagnose, and treat patients with conditions of the head, eyes, ears, nose, and throat. 
  • Review the case study provided by your Instructor. Based on the provided patient information, think about the health history you would need to collect from the patient. 
  • Consider what physical exams and diagnostic tests would be appropriate in order to gather more information about the patient’s condition. Reflect on how the results would be used to make a diagnosis. 
  • Identify three to five possible conditions that may be considered in a differential diagnosis for the patient. 
  • Consider the patient’s diagnosis. Think about clinical guidelines that might support this diagnosis. 
  • Develop a treatment plan for the patient that includes health promotion and patient education strategies for patients with HEENT conditions. 

The Assignment

Use the Focused SOAP Note Template to address the following:

  • Subjective: What details are provided regarding the patient’s personal and medical history?
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any morbidities or psychosocial issues.
  • Assessment: Explain your differential diagnoses, providing a minimum of three. List them from highest priority to lowest priority and include their CPT and ICD-10 codes for the diagnosis. What would your primary diagnosis be and why?
  • Plan: Explain your plan for diagnostics and primary diagnosis. What would your plan be for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: Describe your “aha!” moments from analyzing this case.

By Day 7

Submit your focused SOAP note.


Sample Paper

Episodic/Focused SOAP Note Template


Patient Information:

Initials: S.L

Age: 11 years old

Sex: Male


CC (chief complaint): “My 11-year-old son is nose bleeding. We tried applying pressure but the bleeding won’t stop”.

HPI: the patient, Branch, is an 11-year-old male who presented in the company of his mother with the chief complaint of left-side nose bleeding. Her mother informs that Branch woke up nose bleeding. They tried applying pressure by pinching but the bleeding couldn’t stop. The son however has no history of nosebleeds, no history of trauma, no known allergies, no significant medical history, and is not on any medications.

  • Location: left side
  • Onset: spontaneous
  • Character: persistent
  • Associated signs and symptoms: none
  • Timing: today morning
  • Exacerbating/relieving factors: none

Current Medications: patient denies current/recent use of medications including heparin, warfarin, aspirin, NSAIDs, dipyridamole, and ticlopidine

Allergies: no known food or drug allergy. Reports no environmental allergy

PMHx: up to date with all immunizations, denies history of past epistaxis, systemic or hepatic disease, or hypertension.
Soc & Substance Hx: Branch is a school-going child. He is in 5th grade. He lives with both parents. Mother reports that he loves school and his major hobby is playing football and riding bicycles. He denies tobacco smoking, alcohol use, and recreational drug use. Mother reports he uses seatbelts all the time and wears helmets for safety when riding.

Fam Hx: Maternal and paternal grandparents are alive. Maternal grandmother (70years) is diabetic (well controlled) and the maternal grandfather (75 years) has no chronic illness history. Paternal grandfather died from a hypertensive related complications at 78 years. Paternal grandmother (68 years) is alive and well. Both parents are alive. Mother works as an accountant in a local book store. His father is a high school teacher. There is no history of familial bleeding disorders, coagulopathies, leukemia, or anemia. He has one sibling; a sister, she is 15 years old, alive and well with no history of chronic illnesses. 

Surgical Hx: no previous history of major or minor surgeries

Mental Hx: Branch denies suicidal/homicidal ideations, depression or anxiety.

Violence Hx: denies any safety concerns


General: denies chills, fatigue, or fever

HEENT: Eyes: denies photophobia, vision loss, eye discharge, dryness, irritation, and redness. Ears: denies hearing loss, bleeding, and ear pain. Neck: denies stiffness, pain, swollen glands, and swelling. Mouth & Throat:  denies difficulty swallowing, pain in swallowing, hoarseness, sore throat, dryness, toothache, sores, tongue swelling/pain.

Skin: No rash or itching.

Cardiovascular: denies chest pressure/pain, palpitations, leg cramps, ankle discoloration and swelling, shortness of breath and dyspnea. 

Respiratory: denies wheezing, chest tightness, pain with breathing and cough.

Gastrointestinal: denies poor appetite, vomiting, nausea, diarrhea, constipation, melena, and hematemesis. 

Genitourinary: denies urgency, dysuria, hematuria, odor, retention, and hesitancy.

Neurological: denies headaches, vertigo, dizziness, seizures, blackouts, numbness/tingling, blackouts, poor balance, focal weakness and abnormalities in gait.

Musculoskeletal: denies neck pain, shoulder pain, back pain, hip pain, knee pain, use of medications for chronic pain, denies generalized joint pain, localized deformity and pain, muscle pain, and joint stiffness.

Hematologic: denies anemia, reports continuous nose-bleeding since morning, denies easy bruising, denies past history of prolonged bleeding, or bleeding with minor and major surgeries, or past bleeding episodes.

Psychiatric: denies confusion, irritability, memory loss, mood swings, insomnia, anxiety, and depression.

Endocrinologic: denies heat or cold intolerance, polydipsia and polyuria. 

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.



General Appearance:  healthy appearing middle-aged child, sitting on his mother’s lap with a positive interaction with the informant (mother).

Vital Signs: BP 110/70 P 84 R 14 T 97.8 oral Pulse ox 99%

Skin: normal skin turgor, skin is intact and warm, and capillary refill is 2 seconds, no evidence of petechiae or bruises, no diaphoresis, cyanosis or pallor.

HEENT: Head: normocephalic and atraumatic. Eyes: PEBRL, conjunctivae is clear, EOM without nystagmus and intact, anicteric sclera, intact visual acuity, no periorbital swelling or palpebral edema, no conjunctival exudates, or conjunctival injection. Ears: TM is obscured by cerumen; normal in appearance, auricles are bilaterally symmetrical and intact. Throat: no pharyngeal swelling, erythema or exudates, oral mucosa is moist, pink and without lesions, masses or blood. Neck: no nuchal tenderness, neck is symmetric with painless and free ROM, no JVD or bruits.

Right Nostril: mucosa is atraumatic, no visible foreign body (FB), no active bleeding from the anterior/posterior septum/uncertain location.

Left Nostril: atraumatic mucosa, there is no visible foreign body (FB), minimal active bleeding from the anterior septum.

Respiratory: lung fields clear bilaterally to auscultation, chest expands symmetrically with effortless respirations, no crackles, rhonchi, or wheezing.

Cardiovascular: no murmurs, irregular heart rhythm, friction rubs, ankle edema, or calf tenderness, pedal skin is warm, with equal and good pulses.

Musculoskeletal: all joints with FROM and no gross deformities

Neurological: coordination and balance grossly intact, normal attention and concentration, memory is intact, no gross motor and sensory deficits.

  • Diagnostic Results:
    • CBC (85025;85027; 85007) -pending- to evaluate the patient for platelet disorders, anemia, and neoplasia
    • Coagulation Profile (85730; 85384; 85610; 85670)- Pending-to evaluate the patient for a bleeding disorder


  • Anterior Nose Bleeding ICD10-also referred to as anterior epistaxis, anterior nose bleeding is bleeding from the nostrils and accounts for 90% of nose bleeding cases. It is common among children aged 12 years or younger and the most common site of bleeding is the Kiesselbach plexus (an anastomosis of the ethmoidal, labial, sphenopalatine, and greater palatine arteries) (Yan & Goldman, 2021). Common causes include; nose picking, dry air, and nasal trauma. Patients often report spontaneous onset nasal bleeding with or without a family/genetic history of bleeding disorders. Although this patient had no history of nasal trauma, his age (11 years) and physical exam finding of anterior septal bleeding point towards this diagnosis.
  • Allergic Rhinitis ICD10-refers to swelling and irritation of the nasal mucus membranes. The history may be significant for sneezing, nasal congestion, watery eyes, rhinorrhea and nasal itching. The physical exam may be significant for throat clearing, mouth breathing, allergic shiners, boggy turbinates, tender sinuses, and a post nasal drip Small, (Keith & Kim, 2018). Although Branch reported no history no environmental allergies or a past medical history of allergic rhinitis, a genetic predisposition and being male increases his overall risk of allergic rhinitis. Small, Keith & Kim (2018) explain that in childhood, allergic rhinitis is more common in males than females. The irritation of nasal mucous membranes from rhinitis is what subsequently results in epistaxis.
  • Sinusitis ICD10- Battisti, Modi & Pangia (2021) describe sinusitis as inflammation of the mucus lining of paranasal sinuses. It follows a viral upper respiratory infection resulting in the production of mucus which obstructs the paranasal sinuses allowing an overgrowth of   secondary bacteria. The history may be significant for facial pressure/pain, nasal obstruction, a fever, and postnasal purulence. On physical exam, pertinent positive findings include; periorbital edema, facial swelling, erythema, pharyngitis, cervical adenopathy, and postnasal drainage. Sinusitis causes mucosal inflammation which over time leads to epistaxis (Battisti, Modi & Pangia, 2021). However, since Branch exhibited none of the aforementioned signs and symptoms, it is a less likely diagnosis. 


  • Anterior Nose Bleeding
    • Diagnostic Studies
      • Complete Blood Count (CBC)
      • Coagulation Profile                        
    • Referrals
      • Consult/Refer to an otolaryngologist/ ENT specialist in case the patient develops posterior epistaxis, uncontrollable bleeding, or becomes hemodynamically unstable (Yan & Goldman, 2021).
    • Therapeutic Interventions
      • Rapidly assess airway, overall appearance, stability of the airways, and mental status to determine the need  for  fluid resuscitation and  airway intervention
      • Apply silver nitrate applicator
      • Electrocautery can be indicated.
      • Topical vasoconstriction (adrenaline, cocaine and phenylephrine)
    • Education
      • To get rid of blood cloths that may have formed inside the nostrils, blow your nose gently
      • Do not grip the bony ridge of the nose. Rather, grip the soft part of both nostrils to be able to control bleeding
      • Even when the bleeding is one-sided, do not apply pressure to just one side.
      • Apart from applying pressure, you can also use an ice pack/cold compress to your nose bridge. According to Yan & Goldman (2021), this intervention enhances constriction of blood vessels  and slows bleeding
      • do not insert objects in the nose
    • Planned Follow-Up
      • Follow up in 2 weeks to evaluate for progress and determine the need for further evaluation and management with an ENT specialist/otolaryngologist
    • Health Promotion and Disease Prevention
      • To prevent dryness inside the nostrils, gently smear a thin petroleum jelly layer in the nostrils up to thrice daily before sleep.
    • Allergic Rhinitis
      • Diagnostic Studies
        • Allergen-specific immunoglobulin E (IgE) antibody test.
        • Percutaneous skin test
      • Referrals
        • Should the patient start to experience severe symptoms, referral to an allergy specialist will be appropriate (Sur & Plesa, 2015).
      • Therapeutic Interventions
        • Levocetirizine 5mg PO OD
      • Education
        • To seek immediate emergent medical attention incase new symptoms arise/condition worsens
        • To immediately contact the ER if the son starts experiencing trouble breathing
        • Avoid exposure to allergens such as  dust mites, cold air, mold, and  pet dander
      • Planned Follow-Up
        • Follow up in 2 weeks to assess for symptom control, medication adherence, and need for further evaluation and management
      • Health Promotion and Disease Prevention
        • Avoid exposure to allergens/triggers by keeping pets away from your son’s bedroom, washing and drying your son’s hair every night, wash bedding weekly in warm detergent and warm water, cover box springs, mattresses, and pillows with allergy covers (Sur & Plesa, 2015).


  • Sinusitis
    • Diagnostic Studies
      • plain sinus x-ray
      • Coronal CT scan
    • Referrals
      • Refer to an otolaryngologist/ ENT specialist if symptoms worsen/ there is a new onset of symptoms
    • Therapeutic Interventions
      • Amoxicillin 500mg PO OD for 10 days (Battisti, Modi & Pangia, 2021).
    • Education
      • Use salty water to rinse your mouth.
      • Drink plenty of fluids
      • Apply cold or hot packs
      • Take the prescribed drugs as scheduled
    • Planned Follow-Up’
      • Follow up in 2weeks to evaluate progress and determine the need for further evaluation and management.



This case involves one of the most common ENT emergencies in primary care settings. Interventions may range from the use of home remedies and self-management to more intense and procedural interventions. For patients with severe nose bleeding, this case presented an opportunity for multidisciplinary collaboration with other ENT specialists,


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