| | 27 Case 27 scenario ( loss of hearing )
Doorway information about patient
The patient is a 65-year-old woman who comes to the office due to loss of hearing
Vital signs
. Temperature ; 36.7’C (98.1F)
. Blood pressure : 130/86 mmhm
. Pulse ; 80 /min
. Respirations : 16/min
Basic differential diagnosis
conductive hearing loss
. Cerumen impaction
. Otitis media with effusion
. Tympanic membrane perforation
. Otosclerosis
. Foreign body in ear canal
. cholseteatoma
. Tympanosclerosis
. Tumor of the ear canal or middle ear
Sensorineural hearing loss
. Prescycusis (age-0related hearing loss)
. Ototoxicity
. Noise-induced hearing loss
. Meniere disease
. Diabetes
. Acoustic neuroma
—————
Case 27 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 65-year-old woman who comes to the clinic due to hearing loss
History of present illness
. 3 months of reduced hearing in the left
. Hearing loss was initially mild but is progressively worsening
. Has been difficult to hear people with high-pitched voice
. No associated pain , ringing in the ear , or discharge from the ear
. Admitted to the hospital 4 months ago for a kidney infection and treated with IV antibiotics (you do not recall the name of the drug)
Review of systems
. No dizziness
. No facial muscle weakness
. No weakness or numbness i other parts of the body
Past medical / family / social history
. Hypertension for the last 30 years
. No surgires
. Medications : Hydrochlorothiazide 50 mg daily
. No drug allergies
. Father and mother both died of ‘ old age” ; 2 siblings , both healthy
. Occupations ; Supervisor at a steel factory (If the examinee specifically asks about the noise exposure , say “ there is a lot of noise every day at work.”)
. Married , live with husband
. Tobacco : No
. Alcohol : Occasional beer or wine
. Recreational drugs : No
Physical examination
HEENT :
. PERRLA , EOMI
. Oropharynx clear
. Tympanic membrane clear bilaterally
. Rinne test : Air conduction > bone conduction bilaterally
. Weber test ; localizes to the right ear
Neck:
. Supple
. No lymphadenopathy
. Thyroid normal
Neurologic:
. Alert and oriental to person , place , and time
. Cranial nerves 2-12 intact , except for decreased hearing in the left ear
—————
Case 27 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked which ear is affected (right , left , bilateral)
. Asked about the onset of symptoms
. Asked about the course of symptoms over time
. Asked about the subjective severity of hearing loss(mild , moderate , severe , profound)
. Asked about the possible initiating events
. Asked about associated symptoms , especially:
- Earache
- Tinnitus
- Vertigo
- Aural fullness
- Drainage from the ear
. Asked about any occupational exposure to noise
. Asked about trauma to the ear
. Asked about the social impact that it was had
Past medical /family/social history
. Asked about any similar episodes in the past
. Asked about past medical issues (especially ear. nose. throat and neurologic disorders ) ,hospitalizations , and surgeries
. Asked about current (and recent0 medications
. Asked about medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about occupation
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined eye movements and pupillary reflexes
. Examined facial sensation and motor function (eg , show teeth , puff out cheeks , stick out tongue)
. Examined external ear and ear canal ( with otoscope)
. Tested hearing , including Rinne and Weber tests
Counseling
. Explained physical findings and possible diagnosis
. Explained further workup
Communication skills and professional conduct
. Knocked before entering the room
. Introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Presbycusis
. Occupational exposure
. Ceremony impaction
. Drug induced
Diagnostic study/studies
. Serum electrolytes and blood sugar
. Audiometry
. MRI of the brain
—————
Case 27 clinical summary
Clinical Skills Evaluation
Case 27 Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 65-yo woman with 3 moths of heigh-frequency hearing loss
. Hospitalized for pyelonephritis 4 months ago and treated with unknown antibiotic.
. Exposure to loud noises at work in steel factory.
ROS : No discharge from ear , ringing in ear , dizziness , facial muscle weakness , weakness or numbness in other parts of the body , or earache
PMHx : HTN
PSHx : None
Meds : Hydrochlorothiazide 50 mg daily
Allergies : None
FHx : Father and mother died of old age , healthy siblings
SHx : No smoking , occasional alcohol use
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs : Temperature , 36.7’C (98.1F) ; blood pressure , 130/86 mmHg; pulse , 80/min; and respirations , 16/min
. HEENT : PERRLA , EOMI , oropharynx clear , TMs clear bilaterally , Rinne test with AC>BC , Weber test localization to the right ear , oropharynx clear
. Neck l Supple without lymphadenopathy or thyromegaly
. Neurologic : Alert and oriented to person , place , and time ; cranial nerves II-XII intact except for decreased hearing in left ear
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Presbycusis (age-related hearing loss)
History finding(s)
. Decreased hearing for 2-3 months
. High-Frequency hearing loss
Physical examination finding(s)
. Weber test localization to right ear
Diagnosis #2 : Noise-induced hearing loss
History finding(s)
. Decreased hearing
. Work at still factory with loud noise
Physical examination finding(s)
. Weber test localization to right ear
Diagnosis #3 : Drug-induced hearing loss
History finding(s)
. History of recent antibiotic use
Physical examination finding(s)
. Weber test localization to right ear
Diagnostic studies
. Audiometric testing
. Electrolytes and blood sugar
. MRI of brain
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2018/09/13 07:53am 
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