Epistaxis is a condition of the nasal cavity in which severe bleeding from the nose or nasopharynx
DQ-1
Epistaxis is a condition of the nasal cavity in which severe bleeding from the nose or nasopharynx. Bleeding may result from patients nose picking. Patients with anticoagulant therapy may be more susceptible to nose bleeding. Epistaxis can be a heredity condition. It can also occur because of nasal congestion, sinusitis or upper respiratory infection. Patients may have increased risk of bleeding if they suffer from hypertension, liver disease, traumatic events or overall dry nasal mucosa. Illegal drug use such as cocaine and amphetamines class may trigger nose bleeding. Dry mucosa is more prevalent in the wintertime. For the reasons mentioned above, we begin our assessment with a chief complaint, events leading to current complaint and a patient interview with health history and medication list. The treatment for epistaxis will be initiated followed by Focused physical assessment with general impression of the patient. Initial treatment consists of application of ice on the bridge of the nose. I will advance treatment as needed followed by application of Phenylnephrine spray or Afrin. In the case that treatment does not work insertion of a rhino rocket may be necessary. prophylactic systemic antibiotic may help treat with nasal packing (Murano,Brucato-Duncan,Ramdin, Keller,2019). If bleeding is recurrent a ENT consult may be necessary. I will continue my assessment of the patients head and face for any signs of trauma such as lacerations, contusions bruises, abrasions. Severity of blood loss may be measure by CBC blood test. If trauma is suspected I will order a head CT in order to rule out any skull fractures or intercranial bleeding. Then I will assess the patient’s nasal cavity with an otoscope for any signs of nasal septum deformities or dry mucosa, as well as redness or inflammation of the paranasal. For patients that may appear dehydrated I will treat with oral hydration or IV hydration with normal saline. Other assessments that may be pertinent to this case is abdominal and sclera color assessment. Liver failure may be the contributing factor to coagulation problems. Abdominal distention and yellow sclera may indicate liver failure. If that is suspected patient may need laboratory tests such as CBC,CMP, PT,INR, ammonia level. Other laboratory tests may also indicate the higher risks of patient having an epistaxis event. High MPV levels causes and increase in bleeding tendencies in patients that may have recurrent epistaxis events (Korkut,Bedel,Karancı,Duyan,2020).
Korkut, M., Bedel, C., Karancı, Y., & Duyan, M. (2020). Can We Estimate the Recurrence of Epistaxis with Simple Blood Tests? Journal of Clinical & Experimental Investigations / Klinik ve Deneysel Arastirmalar Dergisi, 11(2), 1–6. https://doi.org/10.5799/jcei/7839
Murano, T., Brucato-Duncan, D., Ramdin, C., & Keller, S. (2019). Prophylactic systemic antibiotics for anterior epistaxis treated with nasal packing in the ED. American Journal of Emergency Medicine, 37(4), 726–729. https://doi.org/10.1016/j.ajem.2018.12.056
DQ-2
Infectious Mononucleosis is described as a viral illness most likely caused by Epstein- Barr virus that affects frequently young adults in their early 20’s and thirty times more common in white compared to black (Riviere, 2020). Epstein Barr Virus is also called a human herpes 4 virus that can only be found in humans (CDC, 2018). The signs and symptoms of infectious mononucleosis are: fatigue, fever, chills, pharyngitis, lymphadenopathy, splenomegaly, headache, tonsillitis, mild hepatomegaly, abdominal pain, nausea, sensitivity to light, erythema- multiforme rash, palatal petechiae or gray-white necrosis of tonsillar tissue in adolescents (Riviere, 2018, p. 180-181). Complete Blood Count, Monospot rapid tests, rapid strep test, throat culture, liver enzymes and ultrasound are some of the diagnostic test used to assess a patient with possible infectious mononucleosis. Complete blood count is used to assess for elevation of lymphocytes, presence of atypical lymphocytes in approximately 20% of the time (Riviera, 2018, p. 181). The enlargement of the spleen that is commonly seen in almost 50% of the patients can be checked by ultrasound (Riviera, 2018, p. 181).
Monospot is a rapid test used to screen patients for presence of heterophil antibodies that appear to be positive during the second or third week of illness. The sensitivity of monospot is 96-99% if the antibodies are increased and almost 90% of the adolescents on the third week of illness showed a positive monospot test. The provider can repeat a monotest after one week from the time that the patient tested negative if the provider still suspect that a patient is at risk for developing infectious mononucleosis. The provider may also order an EBV titer blood test in patients who have unusual signs and symptoms of infectious mononucleosis. According to CDC (2018), monospot is not generally recommended due to some studies showing that monospot can produce a false positive and false negative results (CDC, 2018). It can only show that the patient has a positive cause of infectious mononucleosis but cannot validate the presence of EBV. Viral Capsid Antigen, Early Antigen and EBV Nuclear Antigen (EBNA) are some of recommended antibody testing used to see if the patient has an EBV-associated antigens (CDC, 2018).
Anti-viral Capsid Antigen (VCA) Ig M can be seen in patients who have a new onset EBV infection and usually disappears after four to six weeks (CDC, 2018). Anti-VCA IgG can also be seen in patients with a new onset of EBV infection and peaks within two to four weeks and decreases a little bit and can always be seen for a lifetime. The normal IgG and IgM is less than 1:10 to be negative (Ferri, 2019, p. 172). A patient who has more than 1:10 IgG and IgM anti- VCA is considered positive. A positive IgG can indicate a current or previous infection while a positive IgM is considered a current or recent infection (Ferri, 2019, p. 172). Additionally, an EBV nuclear antigen is described as a standard immunofluorescent test that cannot be seen during the acute phase (CDC, 2018). The normal anti-EBNA is less than 1.5 (Ferri, 2019, p. 172). A result of 1.5 or more can indicate that the patient has a previous EBV infection It can only show two to four months after the signs and symptoms of EBV appears and can last for the rest of the patient’s life. In my experience, I have encountered patients with EBV but not fully aware of the titers and their functionality. Knowing what I know now, I am excited to see and appreciate how doctors and nurse practitioners diagnose and treat patients with EBV.
References:
Centers for Disease Control and Prevention (2018). Epstein Barr| Mononucleosis| Laboratory Testing| Mono| CDC. Retrieved from https://www.cdc.gov/epstein-barr/laboratory-testing.html
Ferri, F. (2019). Ferri’s Best Test: A practical guide to clinical laboratory medicine and diagnostic imaging. Elsevier, Inc. Philadelphia,PA
Riviere, S.L. (2018). Infectious Mononucleosis. Holier, A(Eds). Clinical Guidelines in Primary Care (3rd edition pp. 180-181). Advanced Practice Education Associates, Inc. Lafayette, L.A.
DQ-3
Nasal polyps are benign lesions that are associated with mucosal inflammation of the nasal mucosa to the nasal cavity (Xu, Zhang, Chen, Zhou, & Chen, 2018). Patients may present with congestion, nasal drip, sinus pressure, reduced or loss of smell, and obstruction (Xu et al., 2018). It is important to interview the patient’s medical history for allergic rhinitis, chronic sinus infections, asthma, and cystic fibrosis as these are common causes of nasal polyps (Jobran, Alotaibi, Asiri, Alhayyani, & Almanie, 2018). During the inspection, it is important to check for patency to determine obstruction, the appearance of drainage, and via otoscope inspect the pharynx for nasal drip and nasal mucosa for polyps. Nasal polyps are characterized as pale, saclike lesions that are gelatinous and smooth being about 2-3 cm in size (Jobran et al., 2018). Additionally, the nasal mucosa may be edematous. It is also essential to assess for the cranial nerve I olfactory function to ensure it is intact. A nasal smear or culture can determine for fungal, bacterial, or viral infection. The physical exam should also entail inspecting the eyes for signs of conjunctivitis and allergic shiners and palpating the frontal and maxillary sinuses for tenderness as this may indicate sinusitis. A lung function test can confirm for asthma, and a referral to an allergist would be made for a skin test for suspected allergens. A CT scan would be ordered to evaluate the severity, assess the surrounding sinuses, and identify other abnormalities (Jobran et al., 2018). For further evaluation, the patient would be referred to an ENT specialist.
References
Jobran, B. S. A., Alotaibi, A. E., Asiri, A. Y., Alhayyani, R. M., & Almanie, N. I. (2018). Nasal polyps and its histo-pathological Evaluation. The Egyptian Journal of Hospital Medicine, 11, 2022. doi:10.12816/0044862
Xu, M., Zhang, W., Chen, D., Zhou, H., & Chen, L. (2018). Diagnostic significance of serum periostin in eosinophilic chronic sinusitis with nasal polyps. Acta Oto-Laryngologica, 138(4), 387-391. doi:10.1080/00016489.2017.1388540
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