Epistaxis © MedTx, LLC 2017

erorr: unknown bracket contents - cf-module:CoreCodeReEval
 
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  • CC: year old with pertinent PMH/PSH presents with
  • Focused HPI
    • nose bleeding, 
    •  hx of trauma, 
    • Coagulation history
      • hx of coagulopathy
      • hx of anti-coagulation use
      • hx of liver disease
      • other s/s of bleeding diathesis
    • Anemic Symptoms: 
      •  syncope, 
      • chest pain, 
      • SOB, 
      • fatigue, 
    • hx of prior epistaxis, 
  • HPI:
    • Characteristics obtain from interview with patient:
    • Pertinent positives:
    • Pertinent negatives:
  • REVIEW OF SYSTEMS:
    • Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?
    • Constitutional:
    • ENT:
    • Eye:
    • Cardiac:
    • Pulmonary:
    • GI:
    • GU:
    • Nuero:
    • MSK:
    • Pysch:
    • ID:
    • Endo:
  • EXAM:
    • VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient):
      • HR:
        • normal HR.
        • tachycardic
      • BP:
        • normotensive.
        • hypertensive
          • (attempted to inform pt to advise to f/u with PMD).
        • hypotensive.
      • O2 sat:
        • no hypoxia
        • hypoxic
      • RR:
        • normal RR
        • tachypnic
    • PHYSICAL EXAM:
      • General:
        • well nourished
        • no distress
        • mild distress
        • moderate distress
        • severe distress
      • HEENT:
        • vision grossly intact.
        • hearing grossly intact.
      • Cardiovascular:
        • \ no r/m/g
        • \ no LE swelling
      • Pulmonary:
        • Lungs CBTA,
        • No respiratory distress,
        • Speaking comfortably in full sentences.
        • I/E wheezing,
        • rales,
        • rhonchi,
        • respiratory distress.
      • GI:
        • \ abd soft,
        • \ abd non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ
        • TTP in RLQ
      • Neuro:
        • \ Normal LOC.
        • \ No grossly focal neurological deficits.
        • Somnolent though protecting airway
      • MSK:
        • no deformities,
        • moving all extremities
        • Non-ambulatory.
      • Pysch:
        • Normal speech.
        • Demonstrates linear thinking.
        • No SI/HI.
        • Endorses SI
        • Endorses HI
        • Exam consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
  • Focus Exam (based upon chief complaint)
    • Nose exam:
  • Diagnostically:
    • cbc (to eval for luekocytosis or significant anemia)
    • bmp (to eval for electrolyte derangements)
    • coags
    • type/screen
    • type/cross
  • Therapeutically:
    • -blow out clots
    • -oxymetazoline
    • -direct pressure
    • -silver nitrate if can visualize soure (care was used to not use too much to prevent break in skin/ulcer)
    • -anterior nasal tampon (murecel)
    • -foley inflated
  • Additional Diagnostics/Theraputics
    • module lookup error: CoreCodeED
    • CoreCodeMDM
    • CoreCodeDiagnostically
    • CoreCodeTherapuetically
  •   Assessment/Plan:
    • year old with PMH/PSH of
    • presented with  
    • evaluation is most consistent with
      •  Suspected anterior epistaxis without any evidence of more pathologic process, i.e Suspect anterior given evaluation as well as dramatic improvement w/ initial ED empiric management.
      • Not consistent with posterior epistaxis. 
      • Hemostatic at this time.
    •  Concurrent evaluation for secondary problem is consistent with
    • DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
      • Evaluated and doubt to have coagulopathy, atraumatic hx.  
      • Hemodynamically stable.
      • Suspect anterior nose bleed given history/exam/and resolution of sx with initial ED management.
      • Not consistent with posterior at this taxis given hemostatic, unilateral and nonsevere epistaxis.
      • Not consistent with no which uremia given no history of suggestive of uremia, BUN wnl.
      • Not consistent with coaguloapthy given no history suggestive of bleeding diathesis, coagulation studies within normal limits.
      • Not consistent with traumatic epistaxis given no history of trauma.
      • Not consistent with nasal picking or nasal congestion of their cocaine or other medications given no history of by patient.Not consistent with irritation to nares causing epistaxis given no history of rhinorrhea nor URI symptoms nor allergic sx.
    • Plan:
  • Re-evaluation:
    • Observed for 30 min w/ hemostasis.
    • No indicated for ppx abx with nasal tampon.
    • Facilitated ENT prompt f/u.
    • Advised on appropriate self home care for recurrence of mild epistaxis. Advised of return to ED if persistance/worsening/refractory to brief attempt with pressure.  
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