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Epistaxis in a 62-Year-Old Woman

Epistaxis in a 62-Year-Old Woman

This article was originally presented as an independent educational activity under the direction of CME LLC. The ability to receive CME credits has expired. The article is now presented here for your reference. CME LLC is no longer responsible for the presentation of the article.

A 62-year-old woman presents with epistaxis from the right nostril. The nosebleed has lasted about 90 minutes, and she has become alarmed by the amount of blood on the tissues and washcloth she has applied to her nose. She denies headache, sinusitis, facial pain, diplopia, and chronic rhinorrhea.


She has had a mild upper respiratory tract infection (URTI), from which she is recovering, but otherwise she was previously in good health. At her annual physical examination 2 weeks earlier, new, mild hypertension (142/90 mm Hg) was diagnosed; lisinopril and low-dose aspirin (ASA) were prescribed. Since she did not have “baby” ASA at home, she has been using standard adult tablets instead.

She has had 3 children by vaginal delivery, extractions of permanent teeth, and a cholecystectomy—all without abnormal bleeding. She has no symptoms of heart failure.


Heart rate is 90 beats per minute and blood pressure, 150/96 mm Hg. Examination of the head, eyes, ears, nose, and throat reveals no sign of any cranial neuropathy. There are bruises on the dorsum of the patient’s right hand and on her left shin, but all other physical findings are normal.


Hemoglobin level is 13 g/dL; white blood cell count and platelet count are normal. A chemistry panel and ECG are normal as well. Prothrombin time (PT) and partial thromboplastin time (PTT) are normal; a template bleeding time is 6.5 minutes (normal, 2 to 7 minutes).

Which of the following is most likely responsible for this patient’s epistaxis?
A. A previously undiagnosed congenital coagulopathy, such as von Willebrand disease.
B. Aspirin use.
C. Poorly controlled hypertension.
D. Symptomatic onset of hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome).
E. Presence of a nasopharyngeal neoplasm.

(answer on next page)


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