S:

MA is an 85 yo male with chief complaint of nosebleed. He presents with his son who was used for translation. He started bleeding from his right nostril around 730am this morning after straining during a bowel movement. It has slowed since beginning. The patient held pressure on his nose for fewer than 10 minutes. This is the second occurrence of similar nosebleeds. One occurred 3 months ago. Patient denies digital trauma, foreign bodies, fever, chills, weight loss, rhinorrhea, stuffiness, sneezing, itching, anosmia.

PMH: Septal Deviation, Myocardial Infarction, CVD, HTN, Hyperlipidemia, BPH

PSH: Cardiac Stent Placement 4mos. ago, Septoplasty over 60 years ago

Allergies: NKDA

Medications: Clopidogrel (Plavix) 75mg PO qd, Aspirin 81mg PO qd, Carvedilol 3.125mg PO bid, Furosemide (Lasix) 40mg PO qd, Atorvastatin (Lipitor) 80mg PO qd, Tamsulosin (Flomax) 0.4mg PO qd

FHx: Unknown

SHx: Denies EtOH, illicit substance, tobacco Use

O:

T 98.4°F | BP 118/74mmHg | P 70 BPM, regular | RR 14 breaths/min, unlabored | SpO2 95% RA

H 70in | W 150 lb. | BMI 21.5

Gen: Alert and oriented x 3. Sitting up in hospital bed. Dressed appropriately. Appears as stated age.

HEENT: Nose symmetrical. No masses, lesions, deformities. Dry blood present at right naris. Nares patent bilaterally. Dry blood present on anterior rhinoscopy. Right nasal mucosa injected. Left nasal mucosa pink and well hydrated. Septum midline without lesions, deformity, perforation. No foreign bodies.

Mouth/Pharynx: Oral mucosa pink, well-hydrated. No blood, masses, lesions.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

A:

85 yo male with unilateral R-nostril epistaxis, slowed since beginning. Likely anterior epistaxis secondary to straining.

Differential Diagnosis:

1. Anterior Epistaxis secondary to straining
2. Coagulopathy (antiplatelet medications)
3. Telangiectasias
4. Arteriovenous malformation
5. Neoplasm

P:

Anterior Epistaxis secondary to Straining:

• Instructed the patient to sit in the “sniffing” position, compressing the nares x 15mins. Plan to reassess at that time.
• If cont. bleeding, silver nitrate cautery. If no resolution, consider posterior epistaxis.
• Start Oxymetazoline nasal (Afrin) 2-3 sprays in affected nostril q10-12h prn

Cardiovascular Disease

• Clopidogrel (Plavix) 75mg PO qd
• Aspirin 81mg PO qd

Hypertension

• Carvedilol 3.125mg PO bid
• Furosemide (Lasix) 40mg PO qd

Hyperlipidemia

• Atorvastatin (Lipitor) 80mg PO qd

BPH

• Tamsulosin (Flomax) 0.4mg PO qd

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

Anterior epistaxis secondary to straining                  Anterior Epistaxis secondary to straining

Bleeding Disorder                                                       Coagulopathy (antiplatelet medications)

Coagulopathy                                                              Telangiectasias

Trauma                                                                       Arteriovenous malformation

Dryness of Nasal Mucosa                                           Neoplasm

Allergic Rhinitis

External/Internal Trauma

Foreign Body

Nasal Polyps

Acute Sinusitis

Neoplasm

Telangiectasia

Arteriovenous Malformation (Osler-Weber-Rendu Syndrome)

Septal Deviation or Perforation