Approach to Epistaxis

Group 2

Learning Objectives

• To be able to evaluate the history and physical examination of a patient presenting with epistaxis

• To be able to identify causes and aggravating factors of epistaxis

• To be able to discuss appropriate management options for patients with epistaxis

General Data

M.G 5 year old Female

May 17, 2008 Filipino Roman

Catholic

Taytay Rizal

Source of information: •Mother and aunt•Poor reliability

Chief Complaint

• Nose bleeding

History of Present Illness

1 day PTC• t

he mother’s aunt noticed blood streaked tissue

• yellowish mucoid nasal discharge

• swelling on the right nasal bridge

• (-) fever, no pain, no cough

Morning of Consult• area of discoloration: beginning hematoma , right nasolabial area. • minimal increase in the swelling on the right nasal bridge• (+) colds, yellowish mucoid discharge, cough but with no fever. • (-) consult was done• (-) medications were given

Consult

Review of Systems

• General: No fever, no weight gain, no weight loss, no weakness, no fatigue• Musculoskeletal/ Integumentary: No rashes, no lumps, no sores, no pruritus, no muscle pains, no joint

pains, no changes in color, no joint swelling, no changes in hair/nails• HEENT: no headache, no dizziness, no blurring of vision, no tinnitus, no deafness, (+) throat pain, no

hoarseness, no enlarged lymph nodes• Respiratory: no dyspnea, no hemoptysis, no cough, no wheezing,• Cardiovascular: no palpitations, no chest pains, no syncope, no orthopnea• Gastrointestinal: no nausea,no dysphagia, no constipation, no diarrhea, no rectal bleeding, no jaundice• Endocrine: no excessive sweating, no heat intolerance, no polyuria, no excessive thirst, no cold intolerance• Genitourinary: no dysuria, no sexual dysfunction, no penile bleeding or discharge noted, no frequency, no

hesitancy, no nocturia, no hematuria• Neurological: no seizures, no tremors

Past Medical History

•(-) Asthma•(-) Allergies•(-) Heart, Liver, Thyroid, Kidney, Blood DiseaseComorbids

•Congenital Hydrocephalus•Pneumonia (2012)Hospitalizations

•s/p Ventriculo-Peritoneal Shunting (2008) at PCMC

Surgical Procedures

•Acute Tonsillopharyngitis: Day 4 Co-AmoxiclavConditions

•Paracetamol•Co-AmoxiclavMedications

(+) Hypertension: Father

(+) Diabetes Mellitus: Mother

(-) Asthma(-) Allergies

(-) Thyroid disease(-) Liver disease(-) Kidney disease(-) Blood dyscrasias

Family Medical History

Birth History

Full term

Congenital Hydropceph

alus

NSD VP

Shunting (2008)

24 yo

G1P0 OB

•Until 1 year oldBreastfed•2 months (Gain)Formula•6 monthsWeaning age

•Rice•Meat•(-) VegetablesDiet:•NoneAllergies

Immunization History

• Complete: BCG, DPT/Polio, OPV, HIB, Hepatitis B, MMR, Measles, Varicella, Influenza

• Incomplete: Pneumococcal• Unknown: Rotavirus, Hepatitis A, Typhoid

Environmental History

• No pets at home• Cockroaches at night• 2-storey house, well-ventilated, in front of the main road with no nearby factories• No smokers in the house• Regularly cleaned• Daily hygiene – bathe with soap and water every morning; doesn’t wash hands

regularly

Physical Exam

General

Awake

Alert

Not in CP distress

Vitals

BP: 90/60 mmHg

HR: 116 bpm

RR: 20 cpm

Temperature: 39 C

Pain scale: 6/10

Anthropometrics:

Height: 118 cm

Weight: 29.9 kg

BMI: 21

HEENT

• good hair distribution, no alopecia• no masses, supple neck, no cervical lymphadenopathy, non-distended neck veins• anicteric sclerae, pink palpebral conjunctivae, non sunken eyeballs, (+) periorbital

edema right eye• no tragal tenderness, intact bilateral tympanic membrance• (+) swelling and hypermia of right nostril and nasolabial area, (+) dark reddish

crusted material on right nostril with note of tenderness on right nasal bridge, nostril and nasolabial area

• (+) Grade 3 tonsils non hyperemic no exudates noted

Cardiovascular

• Adynamic precordium, apex beat 4th ICS LMCL, distinct S1 and S2, S1>S2 at apex, S2>S1 at base,

Respiratory

• (-) retractions or labored breathing, no masses or pain on palpation of the posterior chest, symmetrical chest expansion, resonant on all lung fields, bronchovesicular breath sounds; (-) crackles, (-) wheezes

Abdominal

• flat abdomen, normoactive bowel sounds, soft abdomen on palpation, (-) masses, no tenderness on light and deep palpation, no organomegaly, abdomen was tympanitic on all four quadrants

Skin and Extremities

• (-) gross lesions on the upper and lower extremities, (+) observable arterial pulse on upper extremities, (-) clubbing, (-) cyanosis, (-) edema, good skin turgor of both upper and lower extremities

Musculoskeletal Exam

• good muscle tone (5/5 on all extremities), no visible muscle atrophy

Neurologic Examination:

• Cranial Nerves I, II: not assessed• III: intact extraocular muscle• IV, V, VI: not assessed• VII: no facial asymmetry• VIII: intact gross hearing• IX, X, XI: not assessed• XII: tongue midline

• Motor: 5/5 on all extremities• Sensory: no sensory deficit

Salient Features

•5 year old female•Nose bleeding•3 day colds with initial clear nasal discharge to yellowish mucoid to dark red•Infection•(-) Trauma•Fever

Subjective

•Febrile, not in CP distress, irritable•Unilateral right periorbital edema, right nasal bridge swelling, right nasal crusting discharge•Other systems unremarkable

Objective