A 46 year-old female with past medical history of DM and HTN presents with 2 days of dizziness and weakness. She was discharged 3 days ago after being diagnosed with methicillin-sensitive Staphylococcus aureus endocarditis. She was being treated with extended home IV antibiotic infusions through a PICC. Currently, she denies any chest pain or palpitations. She denies any recent weight gain or weight loss. She has been having a good appetite and is eating well. The patient states that she has been having frequent nose bleeds that began after she was discharged. In years past, she has had occasional streaks of blood on a tissue during cold weather, but now she finds herself having to hold pressure for 10-15 minutes to stop the bleeding. She denies any recent headaches, photophobia, cough, coryza, abdominal pain, nausea, vomiting, diarrhea, or constipation. She has no hematemesis or blood per rectum. There is no family history of bleeding disorders. She has no rashes or skin changes and denies any recent travel.
PSH: None
Allergies: No known drug allergies
Social: Lives at home with her husband with no children; denies any drug use, alcohol or tobacco. She is from the United States.
Meds: Insulin glargine 30u nightly, Amlodipine 10mg Daily. Nafcillin 3gm every 6hrs for 6 weeks
PE:
PE: Tm: 98.6, HR: 106, RR: 18, BP: 106/73
GEN: Lying in bed, well-dressed, and comfortable
HEENT: Minimal crusting of blood at nares bilaterally. Nasal septum midline. No active bleeding.
PULM: Breathing comfortably, speaking full sentences, clear to auscultation bilaterally
CV: Tachycardia, regular rate and rhythm.
ABD: Normal bowel sounds, soft, non-tender, non-distended. No rebound or guarding.
GYN: Normal external and internal, No cervical motion tenderness.
Ext: No cyanosis, clubbing, or edema.
Labs:
Na: 140, K: 4.2, Cl: 99, Bicarb: 22, BUN: 21, Cr: 0.96, Glucose: 125
Protein: 6.5, Albumin: 2.09, Calcium: 7.8, AST: 18, ALT: 4, Alk Phos: 158, Tbili: 1.6,
WBC: 15, Hb/Hct: 9/27, Plt: 14
PT: 16.3 PTT: 34 INR: 1.4
BHCG: negative
Lactate 3.8
ECG: Sinus tachycardia
The patient starts to experience another nose bleed in front of you. It’s controllable with pressure and does not alter the existing symptoms of dizziness and lightheadedness.
How would you manage this patient?
If you had access to the medical records, what other information could be useful?
What is your leading differential diagnosis?
Steven Greenstein
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