Nose Disorders CAM I PDF

Nose Epistaxis: ​ Subjective ○​ HPI: ​ A 56-year-old male presents with recurrent episodes of nosebleeds over the past week, primarily from the right nostril. He describes the bleeding as mild to moderate in volume,...

Nose Epistaxis: ​ Subjective ○​ HPI: ​ A 56-year-old male presents with recurrent episodes of nosebleeds over the past week, primarily from the right nostril. He describes the bleeding as mild to moderate in volume, lasting about 10–15 minutes before stopping after applying pressure. The most recent episode occurred this morning while he was brushing his teeth. He denies trauma, nose picking, or recent upper respiratory infections. The patient reports nasal dryness and occasional crusting. He denies symptoms of sinus congestion, fever, or facial pain. There is no history of heavy or prolonged bleeding with cuts, surgeries, or dental procedures. He is otherwise feeling well. ○​ Pertinent PMH: ​ Uncontrolled HTN ​ Seasonal allergic rhinitis ○​ Pertinent social: ​ Construction manager ​ Smokes 1 pack/day x 20 yrs ○​ ROS: ​ Objective ○​ Pertinent PE: ​ Visible crusting in anterior septum. Prominent vascularization noted in Kiesselbach’s plexus. ​ Plan ○​ For anterior: initial tamponade (blow nose, spray nares w oxymetazoline), cauterization (silver nitrate, diathermy, electrocautery), packing (lidocaine & topical epinephrine) ○​ For posterior: insert posterior nasal packing, urgent ENT consult/hospitalization, heme consult for bleeding disorder (if necessary) Allergic rhinitis (hay fever): ​ Subjective ○​ HPI: ​ A 28-year-old female presents with a three-month history of nasal congestion, sneezing, and itchy eyes. The symptoms occur daily, are worse in the morning, and are exacerbated by exposure to dust and during visits to her grandmother's house (who has a cat). She reports intermittent clear nasal discharge and frequent throat clearing but denies fever, chills, or purulent nasal drainage. Antihistamines provide temporary relief. She denies sinus pain, ear pain, or recent respiratory infections. ○​ Pertinent PMH: ​ Mild asthma, well-controlled w PRN albuterol inhaler ​ Seasonal allergies ​ Objective ○​ Pertinent PE: ​ Nasal mucosa pale w clear rhinorrhea & turbinate edema ​ Cobblestoning of posterior pharynx ​ Plan ○​ Allergen avoidance, nasal saline sprays, intranasal corticosteroids (fluticasone) ○​ During pregnancy ​ Intranasal cromolyn sodium (1st line), 2nd gen antihistamines preferred (loratadine, cetirizine), 1st gen antihistamines (chlorpheniramine), intranasal corticosteroids (for moderate-severe), montelukast only if pt benefited prior to pregnancy, nasal saline ​ AVOID ANTIHISTAMINE NASAL SPRAYS, ORAL/NASAL DECONGESTANTS, & INITIATING IMMUNOTHERAPY Non-allergic rhinitis: ​ Subjective ○​ HPI: ​ A 45-year-old female presents with a one-year history of persistent nasal congestion and clear rhinorrhea. Symptoms occur daily, are not seasonal, and do not seem to be triggered by specific allergens or environmental factors. She notices that exposure to strong odors, such as perfumes or cleaning products, and changes in temperature exacerbate her symptoms. Over-the-counter antihistamines have provided little relief. She denies sneezing, itching, or watery eyes. There is no history of trauma, sinus infections, or recent respiratory illnesses. ○​ Pertinent PMH: ​ Controlled GERD ​ Objective ○​ Pertinent PE: ​ Nasal mucosa mild edema, no erythema or discharge ​ Assessment ○​ Diagnosis requires chronic presence of 1+ of the 4 following symptoms: nasal congestion, post-nasal drainage, sneezing, rhinorrhea ​ Plan ○​ Topical intranasal glucocorticoids (budesonide) ○​ Topical antihistamine (azelastine) ○​ Combination most effective (fluticasone/azelastine) ○​ Nasal saline irrigation Rhinitis medicamentosa: ​ Subjective ○​ HPI: ​ A 38-year-old male presents with a 3-month history of persistent nasal congestion. He reports initially using an over-the-counter nasal decongestant spray (Afrin) for a cold, which resolved after a week, but he continued using the spray because it "worked so well." Over time, the congestion worsened, and he now requires the spray multiple times a day to get any relief. When he tries to stop, the congestion becomes unbearable. He denies sneezing, nasal itching, or discharge, and he has no associated sinus pain, fever, or other symptoms of infection. ○​ Pertinent PMH: ​ Seasonal allergic rhinitis during childhood ​ Objective ○​ Pertinent PE: ​ Nasal mucosa erythematous w edematous turbinates w no significant discharge ​ Plan ○​ Withdraw usage of intranasal decongestants ○​ Can use intranasal glucocorticoids if necessary Acute rhinosinusitis (common cold): ​ Subjective ○​ HPI: ​ A 32-year-old male presents with a 10-day history of nasal congestion, facial pressure, and thick nasal discharge. Symptoms began after he developed a common cold, which initially improved after 3–4 days but then worsened. He describes dull pain and pressure over his cheeks and around his eyes, worse when bending forward. Nasal discharge is yellow-green, and he occasionally feels post-nasal drip. He denies fever, chills, or significant fatigue but reports mild headache and decreased sense of smell. He has no recent history of similar episodes or sinus infections. ○​ Pertinent PMH: ​ Seasonal allergic rhinitis ​ Objective ○​ Pertinent PE: ​ Nasal mucosa edematous w erythema. Thick yellow-green discharge bilaterally. Tenderness to maxillary sinuses. ​ Assessment ○​ Likely bacterial (S. pneumoniae, H. influenzae, M. catarrhalis) due to duration & “double worsening” ​ Plan ○​ Bacterial (>10 days) ​ Uncomplicated ​ Antibiotics ​ Complicated (persistent 102ºF+, complication on imaging, CN palsies, abnormal EOM, etc) ​ Urgent referral ○​ Viral (