Nasal Disease PE (e.g., Rhinitis, Nasal Polyps)

Subjective:
Chief Complaint:
Nosebleeds and hearing loss

History of Present Illness:
Mr. Lee, a 77-year-old male residing in xxx, presents with recurrent nosebleeds and hearing loss. The nosebleeds, primarily from the right nostril, have been frequent and significant, staining towels, with recent episodes in February and March. He attributes this to his long-term aspirin therapy, which he has been on for over ten years due to cerebrovascular stenosis. He denies any bleeding from the left nostril and has not used cotton swabs for nasal application. Additionally, Mr. Lee reports anosmia, unable to perceive odors, and bilateral hearing loss affecting both ears, though not classified as a disability. His medical history includes cerebrovascular stenosis, managed with aspirin, a cholesterol-lowering agent, and another vascular medication. He denies hypertension or other chronic diseases.

The Review of Systems:
ENT: Reports recurrent nosebleeds primarily from the right nostril, with significant bleeding episodes in February and March. Denies left nostril bleeding. Reports anosmia and bilateral hearing loss, moderate to severe, not classified as a disability.
Neurological: Denies hypertension.
Hematologic: Prolonged aspirin use may contribute to nosebleeds.

Current Medications:
Aspirin, cholesterol-lowering medication, vascular medication for cerebrovascular stenosis.

Allergies:
The patient has no known drug, food, or environmental allergies.

Objective:
Physical Examination:
Nose:
- Inspect external nose: normal
- Use nasal speculum:
  - Turbinates: normal color
  - Septum: normal
  - Ulcers: absent
  - Polyps: absent
  - Little’s area: normal
  - Nasopharynx: normal
  - Adenoids: normal
  - Eustachian tube orifice: normal

Assessment:
Problem:
1. The patient presents with recurrent epistaxis primarily from the right nostril, likely exacerbated by long-term aspirin therapy. Reports anosmia, possibly due to age-related olfactory decline or cerebrovascular insufficiency. Bilateral hearing loss, moderate-to-severe, may contribute to cognitive decline if unaddressed.

Differential Diagnosis:
1. Aspirin-induced epistaxis (E935.3): Long-term aspirin use likely contributes to recurrent nosebleeds.
2. Age-related olfactory dysfunction: Anosmia may be due to age-related decline.
3. Cerebrovascular insufficiency-related anosmia: Cerebrovascular stenosis may impair olfactory nerve function.
4. Presbycusis (389.18): Bilateral hearing loss consistent with age-related sensorineural hearing loss.
5. Cognitive decline (758.0): Hearing loss and anosmia may increase cognitive impairment risk.

Plan:
• Recurrent nosebleeds: Advised saline nasal spray twice daily and petroleum jelly application to maintain nasal hydration. Avoid forceful nasal cleaning. Consult neurologist about aspirin and vascular medication.
• Anosmia: Install smoke detectors with auditory alarms. Avoid consuming leftover food.
• Hearing loss: Referral to audiologist for evaluation and hearing aids. Address hearing loss to improve communication and reduce cognitive decline risk.
• Cerebrovascular narrowing: Adhere to medication regimen. Follow up with neurologist for ongoing management and medication discussion.