MDM - Epistaxis

[##]-year-old [male/female] with history and exam consistent with epistaxis from [anterior/posterior] source.

Initial considerations in this patient included anterior and posterior vessels as a source of epistaxis, nasal bone fracture and displacement, coagulopathy, nasal foreign body, and nasal tumor among others.

Patient presented [with/without] reported trauma [describe mechanism] with bleeding [not/poorly/minimally] controlled with direct pressure.  On exam the patient was noted to have [no] evidence of symptomatic anemia in the setting of report of approximately [##] mL of blood loss.  Patient [reports/denies] current use of anticoagulants [describe medication/but does report current use of Aspirin].  Direct nasal pressure applied upon presentation to the ED [with/without] adequate control of bleeding.  [Anterior/Posterior] packing with [a anterior Rapid Rhine/Merocel/Foley catheter/a tranexamic acid (TXA) soaked dressing] placed [with/without] adequate control of bleeding.  On speculum examination of the [right/left] nare a bleeding vessel was identified [and packing was placed/it was cauterized].  [Discussed/Considered holding anticoagulation in the setting of bleeding FURTHER.]  Doubt nasal bone fracture given [absence of significant swelling or deformity/absence of significant trauma].

Epistaxis controlled and patient observed in the ED for [duration] without evidence of re-bleeding.  Prior to discharge, we discussed return precautions, specifically for recurrent bleeding, treatment with [packing/antibiotics/discontinuing anticoagulation/etc.], and follow up with primary care doctor within 1-2 days for repeat evaluation [and consideration of restarting anticoagulation], and the patient demonstrated understanding and agreement with this plan.

MDM - Nasal Fracture

[##]-year-old [male/female] with history and exam consistent with nasal fracture.

Initial considerations in this patient included nasal bone fracture and displacement, septal hematoma, anterior and posterior vessels as a source of epistaxis, and other associated facial bone fracture among others.

Patient presented with report of [describe trauma] with evidence of swelling and deformity consistent with nasal bone fracture.  No evidence of septal hematoma on [speculum] examination of the nares.  Epistaxis well controlled with direct pressure [prior to presentation to/in] the ED.  Reduction in the ED considered, [and performed with appropriate splinting placed due to reasons] but deferred due to significant associated swelling and absence of significant breathing difficulty secondary to nasal swelling.  [No evidence of significant pain or deformity noted/Pain and swelling noted] on palpation of the facial bones with imaging [obtained and notable for findings/felt to not be indicated in the ED].  [No/Minimal] associated periorbital ecchymosis on exam.  No loss of extraocular muscle function, reported diplopia, or other findings suggestive of associated orbital wall fracture.  Doubt associated facial bone fractures at this time based on history and exam.

We discussed discharge with referral to ENT for follow up within 6-10 days for further evaluation and management.  We discussed avoiding blowing the nose to reduce further trauma.  We recommended application of ice to reduce swelling upon discharge.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening pain or findings suggestive of septal hematoma, treatment [with NSAIDs/analgesics/Afrin], and follow up with primary care doctor within 1 week for further evaluation and follow up on ENT referral, and the patient demonstrated understanding and agreement with this plan.