Abnormal narrative bank — focused / at-risk
Six focused abnormal narratives carrying the full necessity chain — finding, severity, comparison, risk, action, notification, and reassessment.
A1 Uncontrolled epistaxis on anticoagulant | Skilled assessment of recurrent epistaxis not controlled after 15 minutes of firm continuous pressure, of moderate volume, in a patient on apixaban with a systolic blood pressure of 182 — new and concerning for an anticoagulation- and hypertension-driven bleed. Pressure was maintained and the patient positioned leaning forward; EMS was activated given the failure to control and the anticoagulation; the provider was notified at 15:30. Blood pressure and blood loss were monitored pending transport (cross-reference Anticoagulation, Hypertension). |
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A2 Posterior / large-volume bleed | Skilled assessment of an epistaxis with a large volume, blood draining into the posterior pharynx, and the patient reporting light-headedness — findings concerning for a posterior bleed with early hemodynamic effect. EMS was activated immediately; the patient was kept leaning forward and monitored for airway compromise and for swallowed blood; the provider was notified at 11:10. Vital signs were monitored pending transport and the estimated volume documented. |
A3 Nasal-cannula pressure injury | Skilled assessment identifying a new area of non-blanching erythema with early skin breakdown at the columella and the nares under a continuous-oxygen cannula — a device-related pressure injury not present at the last visit. The cannula was padded and repositioned to offload the area and an alternative interface discussed; the provider was notified at 14:20 and orders for skin care received. The area was measured and the caregiver re-taught padding and skin checks; the site will be reassessed next visit (cross-reference Wounds, Respiratory). |
A4 Sinusitis with facial cellulitis | Skilled assessment of purulent nasal drainage with facial pain, tenderness over the maxillary sinus, and new cheek swelling and erythema, with a fever of 101°F — findings concerning for sinusitis with facial cellulitis. The provider was notified at 13:05; orders for evaluation and antibiotics were received. The patient was educated on the warning signs of spread (eye involvement, vision change, worsening swelling) and to seek emergency care for them; the swelling and temperature will be reassessed next visit. |
A5 New loss of smell | Skilled assessment of a new loss of smell developing over the past week, with reduced appetite and the patient not noticing food odors — a new change affecting intake and safety. Nasal obstruction was assessed and the provider notified at 10:15; orders for evaluation were received. The patient was educated on food-safety compensation (not relying on smell to detect spoilage or gas) and appetite support; intake and smell will be reassessed next visit (cross-reference Taste/Swallowing, Nutrition). |
A6 Nasal trauma / foreign body | Skilled assessment after nasal trauma with visible deformity, moderate bleeding, and swelling — findings requiring evaluation for fracture. Bleeding was controlled with firm pressure and the nose not manipulated; the provider was notified at 16:10 and orders for evaluation received. The patient was educated on ice, elevation, and avoiding manipulation and on the signs of worsening bleeding or airway compromise; the nose will be reassessed after evaluation. |