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

Practice a case with the AI patient 🤖

Summary:

This scenario involves a patient presenting with recurrent episodes of epistaxis. The candidate is expected to gather a focused history, rule out critical causes, assess the impact on the patient's life, provide first aid advice, and formulate a suitable management plan including lifestyle modifications and follow-up.

Key Points:

Data Gathering / History Taking

• Identify diagnosis early to guide focused questioning.

• Rule out critical causes (e.g., blood thinners, coagulopathy, trauma, recreational drug use like cocaine).

• Clarify:

  • Nature, frequency, duration, and triggers of episodes.

  • Whether bleeding is unilateral or bilateral.

  • Any nasal discharge, weight loss, or systemic symptoms.

• Quantify blood loss and check for posterior drip (down the throat).

• Screen for red flags:

  • Easy bruising, prolonged bleeding, family history of bleeding disorders.

• Explore menstrual history if relevant (female patients).

• Elicit lifestyle risk factors (alcohol, smoking, drugs) sensitively.

Clinical Assessment

• Perform a general physical examination and assess vitals.

• Consider anterior vs posterior epistaxis.

• Review patient’s medications and past surgical history.

Management

• Explain the benign nature of anterior epistaxis while highlighting warning signs.

• First aid demonstration:

  • Pinch the soft part of the nose.

  • Lean forward to avoid blood aspiration.

• Advice:

  • Avoid nose picking and forceful nose blowing.

  • Use saline nasal sprays and petroleum jelly to keep mucosa moist.

  • Consider using a humidifier.

• Discuss cautery and nasal packing if conservative measures fail.

• Provide written leaflets for patient education.

• Arrange follow-up in 1–2 weeks especially if packing is done to prevent infection.

• Ensure safety netting to reassess efficacy of treatment.

Important Considerations

• Tailor questions to establish a holistic view of the patient’s condition.

• Manage time efficiently to cover all domains.

• Establish rapport and be empathetic while avoiding accusatory tone.

• Utilize structured approach to ensure completeness.

Diagnostic Approach

1. Identify epistaxis based on history.

2. Rule out secondary causes (trauma, systemic illness, anticoagulation).

3. Differentiate anterior vs posterior bleeding.

4. Investigate further if red flags present or initial treatment fails.

Management

• Conservative treatment: Pinching, humidification, nasal lubricants.

• Escalation: Nasal cautery, anterior nasal packing.

• Referral to ENT if bleeding persists or is recurrent.

• Safety netting: Warning signs, when to return, and ensuring follow-up.

Communication Skills

• Confirm identity effectively to save time (e.g., "Am I speaking to Lynn Taylor?").

• Use non-judgmental language when discussing sensitive topics (e.g., recreational drug use).

• Reassure and educate with clear, jargon-free explanations.

• Build on patient's knowledge and practices during first aid instruction.

Ethical Considerations

• Respect patient’s dignity and concerns.

• Avoid making assumptions based on rehearsed scripts.

• Ensure informed consent for interventions.

• Practice patient-centered care by individualizing recommendations.

Additional Resources

• NICE guidelines on Epistaxis.

• ENT UK guidelines for nosebleeds.

• GMC "Good Medical Practice" – domains on communication and patient care.