MEDICAL MYSTERY_SOAP FOR CHAPTER 11

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MEDICAL MYSTERY FOR CHAPTER 11 HIS STORY Alex was recently sent home from preschool by his teacher. She called his mother and told her that Alex had been crying off and on all morning, and that he did not want to go out to play with the other children. His mother immediately left work to pick him up. As soon as she arrived at the school, Alex ran to her, crying and inconsolable. Once they got home, Alex acted irritable and fussy. He kept crying and pulling at his ear. His mother was worried because there had recently been a child diagnosed with infectious myringitis at his school, but Alex did not have a fever or runny nose. Thinking that he was coming down with a cold, she gave him some Tylenol syrup, which quieted him down. He slept fitfully that night, and when he woke up, he kept crying and pulling on his ears, first one and then the other. His mother decided that a visit to the pediatrician first thing in the morning was in order. By then, Alex also had a low-grade fever. THE EVALUATION When they arrived in my office, Alex could not keep still and would not let me examine him. His mother said Alex was up to date on all his vaccines and had a normal childhood with no illness or complaints. I noticed that he did not have a cough, skin rash, or a runny nose. Nothing pointed to an upper respiratory tract infection. He was irritable, fussy, and now had a low-grade fever. I had to get the nurse to help hold Alex while I examined his throat, eyes, and ears. THE DIAGNOSIS Although Alex was periodically tugging at both ears, I suspected that there was something wrong with just one of them. I knew that earaches usually do not localize, since the nerve from the ear runs close to the center of the mouth. Sure enough, when I finally got a good look at Alex’s left ear, I suspected that he had a bad case of otitis media. Although this inflammation of the middle ear often begins when infections that cause sore throats, colds, or other respiratory or breathing problems spread to the middle ear, it looked to me as if there might be something lodged in Alex’s ear. I gave his mother a referral to an ENT (ear, nose, and throat) specialist and asked that he be seen right away. THE TREATMENT The ENT specialist discovered that there was a small piece of light-colored chalk lodged in Alex’s ear. The ear canal had been blocked, and once the doctor removed the chalk, she could see clear evidence that Alex was suffering from otopyorrhea, an indicator that infection was present. Alex immediately improved after the removal of the chalk, which he apparently had put in his ear at preschool. A 7-day course of antibiotics resolved his condition completely. CASE CLOSED

Two weeks later, I almost didn’t recognize Alex. He was playing contently in the waiting room and seemed happy to come into my office for a tympanometry test. Happily, his ear had returned to normal. Alex’s mother thanked me for the quick diagnosis and asked me how in the world he might have gotten chalk in his ear. I explained to her that children sometimes place things in their ear canal because they are bored, curious, or copying other children. Any child with an irritated and chronically draining ear should be evaluated for the possible existence of a foreign body. Discussion Questions 1. What is otitis media? Otitis media is an inflammation of the middle ear. 2. Define otopyorrhea . Otopyorrhea is the flow of pus from the ear. 3. Why would infectious myringitis be of concern in a preschool? Infectious myringitis would be a concern in a preschool because it is a highly contagious infection that causes blisters on the eardrum. 4. What would tympanometry be used to measure? Tympanometry would be used to measure disorders of the middle ear.

SOAP NOTE CHAPTER 11 Golden Years Senior Clinic 8/22/16 Kerry Young, NP Mrs. Agatha Beard SUBJECTIVE ▪ Reports dry eyes and difficulty “seeing out of the corners of my eyes the way I used to” over several months ▪ Reports occasional floaters in visual field ▪ Denies eye pain ▪ Denies difficulty performing daily tasks due to vision OBJECTIVE ▪ 87-year-old female ▪ Decreased peripheral vision on visual field testing ▪ Tonometry shows increased intraocular pressure ASSESSMENT ▪ Open-angle glaucoma ▪ Xerophthalmia PLAN ▪ Schedule laser trabeculoplasty ▪ Recommend eye drops to help with xerophthalmia Questions 1. How does laser trabeculoplasty work? Laser trabeculoplasty works by creating openings in the trabescular meshwork, allowing the proper drainage of fluid. 2. Define xerophthalmia and provide the word parts. Xerophtalmia is the dry eye due to a decreased production of tears by tear glands. The word parts are xer (meaning dry) and ophthalmos (meaning eye). 3. If the patient had lost vision at the center of her visual field, instead of the periphery, what disease might be the cause? The disease that might be the cause is macular degeneration.

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CASE STUDY FOR CHAPTER 11 CONSULTATION REPORT Patient Name: John Thomas Date: 10/5/16 Diagnoses: (1) Benign paroxysmal positional vertigo, probably secondary to airplane crash. (2) Possible right temporal bone fracture, longitudinal type. History: Ten years ago, this 45-year-old patient was involved in an accident in which two airplanes collided on a runway. He states that he was hit with debris on the right side of his head and sustained several lacerations on the right side of his head and ear. He had no bleeding from the ear canal and no facial weakness, and at no time lost consciousness. There was some numbness of the right ear canal, which was present for 1 week and then improved. The patient noted immediate hearing loss in the right ear after the accident, which has continued until this time. He has some pressure in the right ear that has persisted since the accident. In addition, the patient has noted momentary vertigo when looking down since the accident. Although the vertigo has improved slightly, the patient has episodes of dizziness at least once a day, which resolves on its own without any intervention. An audiogram was obtained on July 24, 2016, at the time of the patient’s initial visit. This audiogram revealed an average 13 dB [ decibel ] hearing loss through the speech frequencies in the right ear with an average loss of 7 dB loss in the left ear. Speech discrimination was normal in both ears. There was a high-frequency loss of 25 dB in the right ear at 8,000 cycles with only a 5 dB loss in the left ear at 8,000 cycles. It was our impression that the patient had a very mild hearing loss of the right ear with excellent discrimination. An ENG [ electronystagmography ] was obtained on August 23, 2016, because of the history of vertigo. This test suggested vestibular pathology with possible CNS [ central nervous system ] disorder due to optokinetic [ concerning the appearance of twitching movements of the eyes ] results. The patient was unable to perform tasks to the left, and the optokinetic responses were unequal. A CT scan of the temporal bones was obtained on September 2, 2016, and was normal, except for some mucosal thickening of the sphenoid sinus. The patient was treated initially with Antivert 12.5 mg three times a day for dizziness. At a follow-up visit on September 22, the patient stated that the light-headedness and dizziness persisted with no change in condition. He continued to have positional dizziness and mild hearing loss. Physical Exam: Ears, nose, and throat examination revealed normal eardrums, with a healed laceration of the right auricle involving the helix. The nasal septum was deviated slightly to the right with increased mucus. Throat examination was negative. The patient had a positive Dix–Halpike [ a physical exam maneuver that tests for vertigo ]. Impression: The patient’s symptoms are consistent with benign paroxysmal positional vertigo most likely secondary to the airplane accident. He also has a possible right temporal bone fracture, although this was not demonstrated by the CT scan. In many cases, these types of temporal bone fractures are very small and of the longitudinal type and may not be apparent on CT scans. Fortunately, the hearing loss is mild in the right ear and probably will not require a hearing aid. The prognosis for vertigo varies, from complete resolution after a few months to persistent vertigo. The patient has a history of slightly elevated cholesterol, which can result in atherosclerosis that can contribute to benign paroxysmal positional vertigo. In addition, we ordered a 2-hour blood sugar with insulin levels to determine if other factors such as diabetes are contributing to his dizziness. We will follow up with the results of this test as soon as they are available. Sean Milligan, M.D.

Discussion Questions 1. This patient is reported to be suffering from vertigo. What does this mean? Vertigo is the sense of dizziness and the loss of balance. 2. What diagnostic procedure would be used to measure the patient’s hearing loss? Weber and Rinne tests is the procedure used to measure a patient’s hearing loss. 3. What diagnostic procedure would be used to assess damage to the middle ear? Tympanometry tests would be used to assess damage to the middle ear. 4. The doctor had requested an ENG because the patient was experiencing vertigo. Search in your medical dictionary, online medical reference, or other source to determine what an ENG ( electronystagmography ) is. Electronystagmography is a series of tests that detect involuntary rapid eye movements.

MEDICAL MYSTERY_SOAP FOR CHAPTER 11

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