Epistaxis 3

Take a history from this 24 year old Ibiza club DJ with recurrent epistaxis

History

  • Onset

  • Duration

  • Timing – episodic or constant

  • Severity – quantify blood loss

  • Unilateral or bilateral

  • Exacerbating and relieving factors 

  • Previous treatments e.g.  first aid measures, cautery or hospital admissions

  • Associated symptoms – crusting, nasal obstruction, rhinorrhoea, post-nasal drip, headaches, visual disturbance

  • Predisposing events – nasal trauma, digital trauma

  • Constitutional symptoms – weight loss, malaise, anorexia, night sweats

  • Past Medical History – recent sinonasal surgery

  • Drug History – anticoagulants, antiplatelets, direct oral anticoagulants (DOACs), steroid nasal sprays, St John’s Wort, antibiotics

  • Social History – smoking, alcohol, occupation (wood work, nickel, chromium, leather, formaldehyde, cloth fibres), Southeast Asian ethnic origin, cocaine use

  • Family History – Family history of cancer, bleeding disorders

  • Systems review

  • Elicit the patient’s ideas, concerns and expectations 


Conclusion

  • Summarise consultation

  • Thank patient

  • Offer appropriate differential diagnosis

Differential diagnoses to consider*

Trauma

  • Nasal trauma

  • Nose picking

Vascular abnormalities

  • Hereditary haemorrhagic telangiectasia

Infective

  • URTI

  • Rhinitis

Malignancy

  • Primary nasal tumour

  • Juvenile nasoangiofibroma

Other

  • Dry weather

  • Idiopathic

  • Chemical irritants

  • Cocaine abuse

  • Foreign body

  • Septal deformity 

Medication induced

  • Warfarin

  • DOACs

  • Antiplatelets

  • Steroid nasal sprays

*Table not exhaustive


Management


You will be asked to suggest an appropriate management plan based on your presumed diagnosis. Ensure that you offer a complete ENT examination, including nasendoscopy using a three-pass technique, prior to further investigations. 


Bloods should be ordered for full blood count at the minimum, along with a clotting screen especially if the patient is on warfarin. Further investigations will depend on the history and your examination findings. Some examples are below:-

Suspected diagnosis

The following investigations/management strategies may be indicated however you must offer based on the clinical scenario you are given

Sinonasal tumour

CT + MRI (depending on local guidance)

Juvenile Nasoangiofibroma

CT + MRI + angiography

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