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 |
|---|---|---|---|---|
| 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？」 | ~60% |
| Hypertension-related epistaxis | Older patient, known/new HTN, bilateral/posterior | 「有冇高血壓？量過血壓未？」(BP measurement) | ~10% | |
| 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？」 | ~1% |
| 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？」 | ~1% | |
| Sinonasal tumour / NK T-cell lymphoma [4] | Unilateral nasal obstruction, crusting, facial swelling | 「一邊鼻成日塞住？面有冇腫？」 | < 1% | |
| Liver failure / coagulopathy | Jaundice, spider naevi, known liver disease | 「皮膚有冇黃？有冇肝病？」 | < 1% | |
| Pitfalls | Foreign body (children) | Child, unilateral foul discharge | 「（小朋友）一邊鼻有冇臭嘅鼻水？」 | ~2% |
| 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？」 | < 1% | |
| Masquerades | Drugs (anticoagulants, antiplatelets, NSAIDs) [4] | Temporal relationship with medication | 「最近有冇開始食新藥？」 | ~10% |
| Pregnancy (↑blood volume, mucosal congestion) [4] | Reproductive-age female, amenorrhoea | 「有冇可能懷孕？月經正唔正常？」 | ~2% | |
| 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？」 | ~5% |
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)
Elbow Pain
Elbow pain is a clinical symptom arising from injury or inflammation of the bones, joints, ligaments, tendons, or nerves around the elbow, commonly caused by overuse conditions such as lateral or medial epicondylitis, trauma, or arthritis.
Erectile Dysfunction
Erectile dysfunction is the persistent inability to achieve or maintain a penile erection sufficient for satisfactory sexual performance.