Epistaxis
Bleeding from the nasal cavity, most commonly originating from the Kiesselbach plexus on the anterior nasal septum.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Idiopathic anterior epistaxis (Little's area) | Young patient, unilateral, self-limiting, digital trauma, dry climate | 「有冇挖鼻習慣？流血通常自己止到？」 |
| Hypertension-related epistaxis | Older patient, known/new HTN, bilateral/posterior | 「有冇高血壓？量過血壓未？」(BP measurement) | |
| Serious Not To Miss | Nasopharyngeal carcinoma (NPC) [1][2] | Unilateral bloody postnasal drip, ear symptoms, neck mass, Southern Chinese | 「有冇頸粒嘢？鼻水倒流有冇帶血？耳仔塞唔塞？」 |
| Sinonasal tumour / NK T-cell lymphoma [4] | Unilateral nasal obstruction, crusting, facial swelling | 「一邊鼻成日塞住？面有冇腫？」 | |
| Bleeding disorder (ITP, vWD, leukaemia) [3] | Bleeding at multiple sites, petechiae, easy bruising, ↑↑APTT | 「身體其他地方有冇出血？皮膚有冇紅點瘀斑？」 | |
| Liver failure / coagulopathy | Jaundice, spider naevi, known liver disease | 「皮膚有冇黃？有冇肝病？」 | |
| Pitfalls | Hereditary haemorrhagic telangiectasia (HHT) [5] | Recurrent epistaxis + telangiectasia on lips/fingers + FH (AD) + AVM | 「嘴唇手指有冇紅色細血管？屋企人有冇類似情況？」 |
| Foreign body (children) | Child, unilateral foul discharge | 「（小朋友）一邊鼻有冇臭嘅鼻水？」 | |
| Masquerades | Drugs (anticoagulants, antiplatelets, NSAIDs) [4] | Temporal relationship with medication | 「最近有冇開始食新藥？」 |
| Pregnancy (↑blood volume, mucosal congestion) [4] | Reproductive-age female, amenorrhoea | 「有冇可能懷孕？月經正唔正常？」 | |
| Trying to Tell Me Something? | Health anxiety about NPC / cancer | HK context: NPC fear, family/friend diagnosed | 「你係咪擔心係鼻咽癌？有冇認識嘅人患過？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, rapport, set agenda | 「你好，我係X醫生，今日會同你傾大約六分鐘，了解吓你嘅情況。你放心講，我哋慢慢傾。」 | Scores interpersonal marks; establishes trust |
| 0:30–1:30 | Open-ended HPI → characterise epistaxis | 「可唔可以話我知發生咗咩事？流鼻血係邊邊鼻？流咗幾耐？大概幾多血？幾密發生？」 | Chief complaint details; duration, frequency, side, volume |
| 1:30–2:30 | Red flags + associated symptoms | 「有冇鼻塞、聞嘢聞唔到？有冇耳仔塞住、聽嘢差咗？有冇頭痛、面痺？有冇身體其他地方出血，好似牙肉出血、皮膚瘀斑、月經多咗？有冇消瘦、夜晚出汗？」 | Screens NPC, bleeding disorder, malignancy |
| 2:30–3:30 | PMH, drugs, allergy, FH, social Hx | 「你有冇長期病？有冇食薄血丸、亞士匹靈、止痛藥？有冇藥物敏感？屋企人有冇類似問題？你有冇食煙飲酒？做咩工作？」 | Completeness of history; drug causes; HHT family history |
| 3:30–4:30 | ICE + hidden agenda | 「你自己覺得流鼻血係咩原因？（Idea）你最擔心啲咩？（Concern）你今日嚟睇醫生，最想我幫你啲咩？（Expectation）」 | Directly tested in Case Report Form Q3; hidden agenda often = fear of NPC |
| 4:30–5:15 | Signpost → summarise → examination plan | 「我總結一吓：你最近…（簡述），我想幫你檢查吓鼻、面、頸同埋量血壓，可以嗎？」 | Shows clinical reasoning, signposting scores marks |
| 5:15–6:00 | Closing, safety net, empathy | 「多謝你今日嚟，我會安排檢查。如果再大量流血止唔到、或者頭暈、氣促，要即刻去急症室。你有冇嘢想問我？」 | Safety net and closure score highly |
Uncovering the hidden agenda: The patient may present with "just a nosebleed" but really fears nasopharyngeal carcinoma (NPC) — especially in a Southern Chinese / Hong Kong context. Always ask 「你最擔心係咩？」 and explore family/friend experience with NPC.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Onset / Duration | When did it start? How long each episode? | 「幾時開始？每次流幾耐？」 | Acute vs chronic; recurrent suggests structural/systemic | Recurrent → NPC, HHT, bleeding disorder |
| Side | Which nostril? Both? | 「邊邊鼻流血？定兩邊都有？」 | Unilateral → local cause (tumour, septal spur); bilateral → systemic | Unilateral persistent → NPC [1] |
| Volume / Severity | How much blood? Clots? Need to go to A&E? | 「大約幾多血？有冇血塊？有冇去過急症室？」 | Severity grading; need for urgent intervention | Massive → posterior bleed, coagulopathy |
| Precipitant | Trauma? Nose picking? Dry weather? | 「有冇撞親？有冇挖鼻？天氣乾唔乾？」 | Trauma/digital → anterior epistaxis (Little's area) | Idiopathic + recurrent → think deeper |
| Nasal sx (NPC screen) | Blocked nose? Loss of smell? Blood in postnasal drip? | 「有冇鼻塞、聞唔到嘢？有冇鼻水倒流帶血？」 | Blood in postnasal drip is significant in early NPC diagnosis [1] | NPC |
| Ear sx (NPC screen) | Hearing loss? Ear fullness? Tinnitus? | 「耳仔有冇塞住？聽嘢差咗？有冇耳鳴？」 | NPC: hearing loss, tinnitus, aural fullness from Eustachian tube blockage [1] | NPC |
| Neuro sx (NPC screen) | Double vision? Facial numbness? Headache? | 「有冇嘢睇開兩個？面有冇痺？有冇頭痛？」 | Cranial nerve involvement → advanced NPC [1] | NPC with skull base invasion |
| Neck mass | Any lump in the neck? | 「頸有冇粒嘢？」 | Most common initial presenting symptom of NPC is lymphadenopathy [2] | NPC |
| Bleeding elsewhere | Gum bleeding? Easy bruising? Heavy periods? Blood in stool/urine? | 「牙肉有冇出血？容唔容易瘀？月經有冇多咗？大便小便有冇血？」 | Mucocutaneous bleeding pattern → platelet/vWD disorder [3] | ITP, vWD, leukaemia, liver disease |
| Constitutional | Weight loss? Night sweats? Fever? Fatigue? | 「有冇瘦咗？夜晚出汗？發燒？好攰？」 | B-symptoms → malignancy | NPC, haematological malignancy |
| HTN | Known hypertension? Headaches? | 「有冇高血壓？有冇頭痛頭暈？」 | HTN is a systemic cause of epistaxis [4] | Hypertensive epistaxis |
| Drug Hx | Aspirin? Warfarin? NOAC? NSAIDs? Nasal sprays? | 「有冇食薄血丸、亞士匹靈、止痛藥？有冇用鼻噴劑？」 | Drug-induced bleeding; rhinitis medicamentosa [4] | Anticoagulant/antiplatelet-related |
| Allergy | Any drug allergies? | 「有冇藥物敏感？」 | Completeness | — |
| Family Hx | Family history of nosebleeds? NPC? Bleeding disorders? | 「屋企人有冇成日流鼻血？有冇鼻咽癌？有冇出血病？」 | HHT is AD; NPC clusters in families; haemophilia/vWD | HHT, NPC, haemophilia, vWD |
| Social Hx | Smoking? Alcohol? Occupation? Preserved/salted fish? | 「有冇食煙飲酒？做咩工作？細個有冇食好多鹹魚？」 | Smoking → nasal/sinus malignancy; salted fish → NPC risk in HK | NPC, sinonasal carcinoma |
| Functional impact | Affecting work/sleep/daily life? | 「流鼻血影唔影響你返工瞓覺日常生活？」 | Biopsychosocial assessment | Social/functional problem for CRF |
Case Report Form Answer Builder
Format: "Recurrent epistaxis for [duration]"
Must capture: Side (L/R/bilateral), frequency, duration of each episode, volume, precipitants (trauma/nose-picking/spontaneous), associated nasal/ear/neurological symptoms, bleeding elsewhere, constitutional symptoms, drug history (anticoagulants, NSAIDs), PMH (HTN, liver disease, bleeding disorders), FH (NPC, HHT).
| Likely RFC Examples | How to Phrase |
|---|---|
| Worried about cancer / NPC | "Patient presents due to concern that recurrent epistaxis may indicate nasopharyngeal carcinoma" |
| Epistaxis not stopping / getting worse | "Patient presents because nosebleeds are becoming more frequent and difficult to control" |
| Advised by family to see doctor | "Patient presents at family's urging after recurrent nosebleeds" |
Tip: The RFC is NOT the diagnosis. It is the patient's reason for attending today. Ask 「點解今日嚟？」
| Component | Example Wording for CRF |
|---|---|
| Ideas | "Patient thinks nosebleeds may be due to dry weather / nose picking / high blood pressure" |
| Concerns | "Patient is worried it could be nasopharyngeal carcinoma, as a relative was diagnosed with NPC" |
| Expectations | "Patient wants reassurance and possibly a referral for nasal endoscopy / blood tests" |
In an FM station with a young/middle-aged patient and isolated recurrent epistaxis without red flags → Idiopathic anterior epistaxis (Little's area)
If the stem includes HTN → Hypertensive epistaxis
If the stem includes unilateral bloody postnasal drip + ear symptoms + neck mass → Nasopharyngeal carcinoma
Minimum supporting evidence: Location (anterior), self-limiting, no systemic bleeding, normal BP, no neck mass, no ear symptoms.
| DDx | Key Discriminator |
|---|---|
| 1. Nasopharyngeal carcinoma | Unilateral blood-stained postnasal drip, neck mass, ear fullness, CN palsy; Southern Chinese |
| 2. Hypertension | Elevated BP on measurement, posterior bleed, older age |
| 3. Bleeding disorder (e.g. ITP / vWD) | Bleeding at multiple mucocutaneous sites, petechiae/purpura, prolonged bleeding, FH |
| Type | Problem |
|---|---|
| Biological | Recurrent epistaxis causing anaemia / iron deficiency |
| Psychological | Anxiety about underlying cancer (NPC) |
| Social | Functional impact — avoidance of social activities / work absenteeism due to unpredictable nosebleeds |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports |
|---|---|---|---|
| Idiopathic anterior epistaxis | Visible anterior septal vessel prominence / crusting at Little's area | Anterior rhinoscopy with headlight & nasal speculum; look at anterior septum | Little's area (Kiesselbach's plexus) is the most common site of anterior epistaxis |
| NPC [1][2] | Cervical lymphadenopathy (Level II, bilateral) | Palpate anterior and posterior triangles of neck bilaterally | Most common initial presenting symptom of NPC; firm, non-tender nodes |
| Hypertension | Elevated blood pressure ( > 140/90 mmHg) | Standard BP measurement in both arms | HTN is a recognised systemic cause of epistaxis [6] |
| Bleeding disorder | Petechiae / purpura on skin (esp. dependent areas) | Inspect shins, forearms, oral mucosa | Mucocutaneous bleeding pattern indicates platelet-type disorder [3] |
| HHT | Telangiectasiae on lips, tongue, fingertips [5] | Inspect lips, oral mucosa, nasal mucosa, fingertips | Triad of FH (AD) + recurrent epistaxis + telangiectasia/AVM = HHT |
Must-Not-Miss Red Flags → Urgent Referral
- Unilateral bloody postnasal drip + serous otitis media + neck mass → suspect NPC → urgent ENT referral + nasopharyngeal endoscopy + EBV serology [1][2]
- Massive uncontrollable epistaxis → A&E; may need posterior packing / arterial embolisation
- Bleeding at multiple sites + petechiae → CBC urgently; consider leukaemia, ITP, DIC
- New neurological signs (diplopia, facial numbness) → NPC with skull base invasion → urgent imaging
- Recurrent epistaxis + telangiectasia + FH → HHT → screen for visceral AVMs [5]
Common Traps That Lose Marks
- Forgetting NPC in a Hong Kong patient — the examiners expect you to screen for NPC ear/nose/neck symptoms. This is the #1 "serious not to miss" in HK FM.
- Not asking about drugs — anticoagulants and antiplatelets are a very common cause in elderly patients.
- Not checking BP — hypertension is listed as a systemic cause on GC slides [4]. Always state you would measure BP.
- Writing "epistaxis" as the RFC — the RFC is WHY they came today (e.g. fear of cancer), not the symptom itself.
- Missing ICE — this is directly marked. Always ask all three components explicitly.
- Confusing haemoptysis with epistaxis — epistaxis may present as blood in the mouth or be swallowed causing haematemesis / melaena. GC slides highlight epistaxis as a mimicker of upper GI bleeding [7] and a differential for haemoptysis [8].
Shortest safe management / safety-net line: 「如果流鼻血超過二十分鐘止唔到，或者大量出血、頭暈，請即刻去急症室。」 ("If nosebleed doesn't stop after 20 minutes, or there is heavy bleeding or dizziness, go to A&E immediately.")
High Yield Summary
What to ASK: Side, frequency, volume, postnasal blood, ear symptoms (hearing loss/tinnitus/fullness), neck mass, facial numbness/diplopia, bleeding elsewhere, drugs (anticoagulants/NSAIDs), BP history, FH (NPC, HHT), ICE — especially cancer fear.
What to WRITE: Chief complaint with duration; RFC = why today (often fear of NPC); ICE explicitly; most likely Dx with supporting evidence; DDx including NPC, HTN, bleeding disorder; biopsychosocial problems; one physical sign (anterior septal vessels for idiopathic, neck nodes for NPC, BP for HTN).
What NOT to MISS: NPC in a HK patient (postnasal blood, ear sx, neck mass); drug-induced bleeding; HHT (telangiectasia + FH + recurrent epistaxis); always measure BP; always ask ICE.
Active Recall - Family Medicine Clinical Test
[1] GC 215. Common nasal conditions and nasopharyngeal carcinoma.pdf (pp. 3, 51) [2] MBBS Final MB (Surgery) (Felix PY Lai).pdf (p. 251 — NPC clinical features and diagnosis) [3] MBBS Final MB (Medicine) (Felix PY Lai).pdf (pp. 1354, 1369 — platelet vs coagulation bleeding patterns, ITP) [4] CFB WCS29_Common ENT conditions 2023.pdf (p. 9 — Epistaxis causes: local and systemic) [5] Introduction to Clinical pharmacology (I) (Pharmaco-Genomics, Precision Medicine).pdf (p. 2 — HHT case); Maksim Medicine Notes.pdf (p. 280 — HHT triad); Ryan Ho Fundamentals.pdf (p. 404 — telangiectasiae on lips/fingertips) [6] Block A - High blood pressure: hypertension.pdf (p. 18 — epistaxis as symptom of hypertensive vascular disease) [7] GC 036. Coffee ground vomitus/tarry stool_upper GI bleeding.pdf (p. 29 — epistaxis as mimicker) [8] General clerkship Teaching Clinic - Haemoptysis_Prof MSM Ip_25 October 2024.pdf (p. 44 — epistaxis vs haemoptysis)
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