Duration of hemorrhage and side of initial bleeding should be noted. History of epistaxis, hypertension, hepatic or other systemic disease, easy bruising, or prolonged bleeding after minor surgical procedures should be sought. Recurrent episodes of epistaxis, even if self-limited, should raise suspicion for significant nasal pathology. Nausea is a possible symptom. Massive epistaxis may be confused with hemoptysis or hematemesis.
Blood dripping from posterior nasopharynx confirms a nasal source.
Perform a thorough and methodical examination of nasal cavity. Blowing the nose removes clots permitting a better exam and decreases effects of local fibrinolysis. Application of a vasoconstrictor prior to the exam may reduce hemorrhage and help to pinpoint the precise bleeding site. Topical application of a local anesthetic reduces pain associated with the exam and nasal packing. Gently insert a nasal speculum and spread the naris vertically.