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Epistaxis

Clinical Discipline(s)/Organ System(s)
Emergency Medicine, Otorhinolaryngology
Progress Test Topic(s)
ENT
Description
An 86 year old NZ European woman calls an ambulance when she develops a nose bleed that 'just won’t stop'. Her daughter, who lives with her, has tried pinching the end of her nose but that has not helped. She is taken into the Resuscitation Room. You are asked to obtain some more information from the daughter. She tells you that her mother has been complaining of a blocked nose for the past few months and has had intermittent small nose bleeds.
Applied Science for Medicine 
   - Anatomy of the nose, nasopharnyx, sinuses and facial bones
   - Physiology of olfaction and haemostasis
   - Aetiology and pathogenesis of nasal polyps, anterior and posterior epistaxis, nasopharyngeal carcinoma
   - Basic principles of the development of neoplastic disorders
   - Microbiology of upper respiratory tract infections
   - Pharmacology of vitamin K, glucocorticoids, cocaine, aspirin, clopidogrel, warfarin, abciximab
Clinical and Communication Skills 
   - History of nasal symptoms
   - Examine the nose and upper airway
   - Recognise signs of hypovolaemic shock and a compromised airway
   - Classify the severity of shock
   - Perform a venepuncture, nasal swab, basic airway management
   - Differential diagnosis of epistaxis, nasal blockage
   - Interpret full blood count, coagulation screen, urea, electrolytes, C-reactive protein, anti-neutrophil cytoplasmic antibody (ANCA)
   - Indications for audiogram, CT head, MRI head, nasal endoscopy, nasal biopsy
   - Management of hypovolaemic shock including anticoagulation reversal
   - Outline the management of anterior epistaxis and posterior epistaxis
   - Role of the otorhinolaryngology (ORL) surgeon and haematologist
   - Prognosis for nasopharyngeal carcinoma
Personal and Professional Skills 
   - Empathise with patients with distressing symptoms
   - Explore the role of the family/whānau
   - Self-care regarding contact with blood and other bodily fluids
Hauora Māori 
   - Understanding of inequities in access to health services and quality of medical care for Māori, and application of this to clinical decision making and management
   - Consideration of patient and whānau needs with regard to ‘breaking bad news’
Population Health 
   - Epidemiology of nasal squamous cell carcinoma, granulomatosis with polyangiitis, epistaxis, nasal polyp
Conditions to be considered relating to this scenario
Common
epistaxis, nasal polyp, anticoagulant use, antiplatelet medication use, trauma, foreign body, allergic rhinitis, chronic sinusitis, upper respiratory tract infection, deviated septum, gastro-oesophageal reflux disease
Less common but 'important not to miss'
granulomatosis with polyangiitis (Wegner’s granulomatosis), nasopharyngeal carcinoma, haematological malignancy, immune thrombocytopenia
Uncommon
hereditary haemorrhagic telangiectasia, von Willebrand’s disease, concha bullosa, sarcoidosis
Related Scenarios
[Upper airway disease]