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

2 days PTC (+) colds with clear watery nasal discharge frequent wiping of her nose with tissue. (-) associated fever, cough, history of trauma or manipulation to the nostrils and nasolabial area. No consult was sought and no medications were applied or given 1 day PTC the 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 Afternoon of Consult (+) thick, dark, reddish, crusted material on the patient’s right nasolabial area dried blood admixed with Povidone Iodine applied Vaseline on top of the crusted material Fever (Tmax 39.0 C) and irritability when the cargivers attempted to clean the crusted material. Paracetamol 250 mg/5 ml 6 ml, last dose was at 4 pm (-) History of recent trauma or manipulation to the said area and patient denies inserting any foreign body within the nostril 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

Comorbids (-) Asthma (-) Allergies (-) Heart, Liver, Thyroid, Kidney, Blood Disease Hospitalizations Congenital Hydrocephalus Pneumonia (2012) Surgical Procedures s/p Ventriculo-Peritoneal Shunting (2008) at PCMC Conditions Acute Tonsillopharyngitis: Day 4 Co-Amoxiclav Medications Paracetamol Co-Amoxiclav

Family Medical History (+) Hypertension: Father (+) Diabetes Mellitus: Mother (-) Allergies (-) Asthma (-) Kidney disease (-) Thyroid disease (-) Blood dyscrasias (-) Liver disease

Congenital Hydropcephalus Birth History Full term Congenital Hydropcephalus NSD VP Shunting (2008) 24 yo G1P0 OB

Breastfed Until 1 year old Formula 2 months (Gain) Weaning age 6 months Diet: Rice Meat (-) Vegetables Allergies None

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

Subjective 5 year old female Nose bleeding 3 day colds with initial clear nasal discharge to yellowish mucoid to dark red Infection (-) Trauma Fever Objective Febrile, not in CP distress, irritable Unilateral right periorbital edema, right nasal bridge swelling, right nasal crusting discharge Other systems unremarkable