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A 12 yr old girl came to our Borame hospital with severe  nasal bleeding, spontaneous spasm of the hands mostly seen when she attend to the school, she is briliant girl with the learning all vital signs shows normal, no abnormality was seen on her investigation.
what is your probabaly diagnosis?
what investigation you send?
what is most prababaly treatment you give this pateint?

Although you said it's normal but the investigations you have done for the patient is not yet clear.

What about the medication history as many drug side effects shows combined nose-bleeding and muscle twitching?

Any recent head trauma to exclude neurological cause for the spasms and epistaxis?
If I assume that your patient has no history of trauma or medication, she may be having hypocalcemic tetany.
The mechanism of bleeding in tetany is due to calcium deificiency which is required in the coagulation cascade.
So if there?s a cut, and the person is hypocalcemic, the clotting cascade would progress at a slower rate and cause delayed clotting thus bleeding thus epistaxis!!

I will check the blood calcium level to confirm the diagnosis.

IV calcium gluconate 10% is given slowly in a period of 10 minutes, or if the hypocalcaemia is severe, calcium chloride is given instead.

Hope this is the answer.

I may add the following point

A 12 year old girl in school presented with spasms and nasal bleeding , Two things are important to consider Hypocalcemia (as mentioned by Diagnostic) and Respiratory alkalosis(Due to panic attacks or hysteria) ..

You have pointed that all investigations are normal (if by investigations you mean Blood tests radiology, UA etc) then Respiratory alkalosis is more likely.

If that patient presented to me, Besides Routine investigations (CBC, UA etc) I would send for ABGs and Electrolytes.

If it is hypocalcemia the treatment is mentioned by Diagnostic.
IF Respiratory Alkalosis investigation of the cause is mandatory, history is important here esp if the attack is recurrent in certain situation then psychiatric cause is more likely. Breathing into a bag is usually helpful in emergency cases of alkalosis..

Other things to consider is Vitamin D deficiency which will lead to hypocalcemia and aforementioned symptoms.

The investigation we performed is:
HB ,X-ray of the Skull (Ap & LL),RFT, LFT.
How about the weather of Borama?
plz try 2nd time
Many thanks to Diagnostic,Dr Adnan

Is it epistaxis with Raynaud's phenomenon due to cold weather?!


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