Stopping the Bleed: Mastering Epistaxis - A PLAB 2 Mock Scenario Attempt 1

Practice a case with the AI patient 🤖

Summary:

This PLAB 2 station involves a young adult presenting with recurrent episodes of epistaxis, typically unilateral. The candidate must determine the type of bleed (anterior vs. posterior), assess potential underlying causes, and provide appropriate management and safety netting.

Key Points:

History Taking

• Onset and Triggers:

  • Establish whether bleeding is spontaneous or associated with cold/dry air, sneezing, or nose-blowing.

  • Winter season dryness and irritation are common triggers for anterior bleeds.

• Frequency, Duration, and Severity:

  • Ask about frequency of episodes, duration, and quantity of blood loss.

  • Identify if bleeding persists beyond 20 minutes (suggests severity).

• Bleeding Characteristics:

  • Confirm whether the bleed is unilateral or bilateral.

  • Ask if blood is seen dripping from the nose or going down the throat (suggesting posterior bleed).

• Associated Symptoms:

  • Screen for signs of anemia: dizziness, fatigue, palpitations.

  • Ask about nasal stuffiness, obstruction, or mass sensation (suggests structural issues like polyps or tumors).

• Risk Factors:

  • Rule out trauma, nasal picking, and previous nasal surgery.

  • Inquire about family history of bleeding disorders.

  • Discuss lifestyle factors like cocaine use (requires sensitive signposting), smoking (causes mucosal damage), and alcohol (potential liver-related coagulopathy).

Important Considerations:

• Anterior bleeds (Kesselbach’s plexus) are more common in young adults and generally benign.

• Posterior bleeds (Woodruff’s plexus) are more serious and common in elderly, associated with comorbidities like hypertension.

• Persistent unilateral bleeds require evaluation for tumors, polyps, or vascular malformations.

• Examine for signs of systemic bleeding tendencies.

Diagnostic Approach:

1. Confirm Site and Type:

   • Use history to differentiate anterior vs. posterior bleeding.

2. Assess Frequency and Impact:

   • Document episode characteristics and systemic symptoms.

3. Investigate Underlying Causes:

   • History of trauma, coagulopathies, drug use, or neoplasms.

4. Physical Exam:

   • Visual inspection of nostrils; if indicated, refer for nasal endoscopy.

Management:

• Immediate Advice:

  • Sit forward, pinch the soft part of the nose for 10-15 minutes, breathe through the mouth.

  • Avoid lying back to prevent aspiration.

• Preventative Tips:

  • Use of nasal moisturizers or saline sprays in dry weather.

  • Humidification of room air.

• Further Investigations:

  • FBC for anemia.

  • Coagulation profile if bleeding disorder is suspected.

• Referral:

  • ENT referral if recurrent, severe, or suspicious features (e.g., mass, unilateral persistent bleeds).

• Lifestyle Modifications:

  • Stop smoking.

  • Avoid nasal trauma (no nose picking).

  • Educate on proper nose-blowing technique.

• Safety Netting:

  • Advise to seek help if bleeding lasts >20 minutes, is bilateral, or associated with systemic symptoms.

Communication Skills:

• Confirm patient identifiers correctly (full name and age).

• Avoid repetition; build on patient responses.

• Use patient’s own words to start the consultation.

• Signpost sensitive questions, e.g., substance use.

• Avoid rehearsed or overly formal language; maintain a conversational tone.

Ethical Considerations:

• Ensure confidentiality.

• Avoid making assumptions based on age or lifestyle.

• Use appropriate consent procedures during examination and history.

Additional Resources:

• NICE Guidelines on epistaxis

• GMC Good Medical Practice: Domains on communication, professionalism, and patient care

• Examiner tips on avoiding rehearsed phrases and focusing on real interaction