CC: “Nosebleed that won’t stop”
HPI: A 66 year old white male, with history of Type II diabetes, gout, hypertension and coronary artery disease status post 3 stent placement most recent 2009. was transferred to UF Health, from a medical center in The Villages, Florida for ENT evaluation of persistent unilateral epistaxis of the right nostril. The three days prior to admission, the patient admitted that while taking a shower he cleared his nose and “red chunks” were seen, he also noted some hoarseness. The patient awoke from sleep on the morning of admission around 3am and noticed continuous bleeding from his right nostril, which he described as a bright red fluid with darker clots. The patient states that this is his first episode of epistaxis. …show more content…
Pulmonary: No signs of respiratory distress. Decreased breath sounds bilaterally, with no wheezing, crackles, rales or rubs. No tenderness on palpation.
Cardiovascular: On auscultation of sternal border: RRR with no murmur, clicks, rubs, splitting or abnormal sounds noted. (Placement of cardiac electrodes prevented visualization and palpation of the aortic, pulmonary, and mitral areas; PMI not identified). No carotid bruit detected on auscultation. Carotid, brachial and radial pulses symmetrical, regular and strong. Dorsalis pedis and posterior tibial pulses symmetrical, regular and strong.
Abdominal: Symmetrically distended abdomen. Scars consistent with laparoscopic cholecystectomy. No distended veins or visible peristalsis. Diminished bowel sounds in all four quadrants; no bruits. Tympany on percussion in all four quadrants. Spleen and liver impalpable.
Neuromuscular: The patient is alert and oriented x4. All cranial nerves intact. No tremor, tics, atrophy, or extremes in muscle tone.
ASSESSMENT AND
HPI: A 66 year old white male, with history of Type II diabetes, gout, hypertension and coronary artery disease status post 3 stent placement most recent 2009. was transferred to UF Health, from a medical center in The Villages, Florida for ENT evaluation of persistent unilateral epistaxis of the right nostril. The three days prior to admission, the patient admitted that while taking a shower he cleared his nose and “red chunks” were seen, he also noted some hoarseness. The patient awoke from sleep on the morning of admission around 3am and noticed continuous bleeding from his right nostril, which he described as a bright red fluid with darker clots. The patient states that this is his first episode of epistaxis. …show more content…
Pulmonary: No signs of respiratory distress. Decreased breath sounds bilaterally, with no wheezing, crackles, rales or rubs. No tenderness on palpation.
Cardiovascular: On auscultation of sternal border: RRR with no murmur, clicks, rubs, splitting or abnormal sounds noted. (Placement of cardiac electrodes prevented visualization and palpation of the aortic, pulmonary, and mitral areas; PMI not identified). No carotid bruit detected on auscultation. Carotid, brachial and radial pulses symmetrical, regular and strong. Dorsalis pedis and posterior tibial pulses symmetrical, regular and strong.
Abdominal: Symmetrically distended abdomen. Scars consistent with laparoscopic cholecystectomy. No distended veins or visible peristalsis. Diminished bowel sounds in all four quadrants; no bruits. Tympany on percussion in all four quadrants. Spleen and liver impalpable.
Neuromuscular: The patient is alert and oriented x4. All cranial nerves intact. No tremor, tics, atrophy, or extremes in muscle tone.
ASSESSMENT AND