Patient is a 25-year-old male who presents with a several hour long nosebleed. He stated he was in usual state of good health when his nose started bleeding after he blew it particularly hard. He denies any injury to his nose. He has no history of liver disease or hypertension. Patient is on no medication, either prescription or over-the-counter.
The bleeding did not stop even after applying pressure to the right nares, pressing it against the septum for 10 minutes. A nasal speculum was used to examine the internal nares, and the source of the bleedinga small veinwas noted. The vein was chemically cauterized with a stick of silver nitrate. The patient tolerated the procedure well. He was observed for another hour and when the bleeding did not start again, he was instructed to not blow his nose for at least 48 hours and to contact his PCP for follow-up.
Dx: Epistaxis
What will be an ideal response?
Question 2
The 37- year-old female was seen in the office with complaints of a rapid heartbeat. She stated her pulse rate was 120 most of the day. She had no fever and no dehydration. She denied use recreational drug use. EKG was within normal limits, with the exception her heart rate, which was in 115 to 120 range. The physician suggested she watch her caffeine intake. She was also asked to follow-up with her PCP in a week.
Please code all the diagnoses, scenarios and procedures.
Impression: Sinus tachycardia
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