1. Approach to Epistaxis
Group 2

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

3. General Data M.G 5 year old Female May 17, 2008 Filipino
Roman Catholic
Taytay Rizal
Source of information:
Mother and aunt
Poor reliability

4. Chief Complaint
Nose bleeding

5. History of Present Illness

6. 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

7. 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

8. 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

9. 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

10. Past Medical History

11. 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

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

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

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

15. Immunization History
Complete: BCG, DPT/Polio, OPV, HIB, Hepatitis B, MMR, Measles, Varicella, Influenza
Incomplete: Pneumococcal
Unknown: Rotavirus, Hepatitis A, Typhoid

16. 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

17. Physical Exam

18. 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

19. 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

20. 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

21. 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

22. 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

23. Salient Features

24. 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