Transcript Pain Problem Case - University of Minnesota Duluth

Inner Ear Case
Mr. Rodney Mott
Chief Complaint: Trouble hearing
and problems with dizziness
Med 6573: Nervous System
University of Minnesota Medical School Duluth
17 and 20 February 2006
Drs. Nordehn, Forbes & Fitzakerley
YOU MUST PREPARE PRIOR TO THE SESSION ON
FRIDAY, FEBRUARY 17 2005, 9:00 A.M.
Review the information provided in this handout relative to:
Mr. Mott’s present and past history, meds, allergies and habits.
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Note significant data.
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Try to answer the questions that are posed on slide 5.
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Be prepared to discuss the case.
Mr. Rodney Mott is a 46-year-old carpenter, who has trouble hearing and some
problems with dizziness.
History of the Present Illness: Mr. Mott noted he was having trouble hearing
his teakettle. At times he heard whistling in his ears that was not the teakettle
and at other times he could not hear the kettle when it did whistle. This has
been going on for several months, getting gradually worse in both ears.
One morning, about three months ago, while getting out of bed, he began to
hear whistling in his ears that became progressively louder. At the point where it
was becoming annoying, he suddenly felt the room begin to spin. He sat down,
but this gave him no relief. He became nauseated and eventually vomited.
Because the spinning persisted, he climbed back into bed and found himself to
be more comfortable when he lay on his right side with his eyes open. Within
one half hour the spinning had stopped and the whistling also diminished.
Since then, he has had several similar episodes, each beginning with increasing
whistling followed by the spinning sensation. Mild hearing problems and
whistling in both ears persist but the sounds seem louder in his left ear.
Between his attacks he feels quite well and has no difficulty with his strength
and coordination.
Past Medical History: Usual childhood illnesses. No history of heart disease,
diabetes, stroke, convulsions or hypertension. Approximately 5 years ago, he was
hospitalized for severe burns on his hands and forearms . He remembers being
told that the IV he was given contained antibiotics. He resents the fact that he is
still paying for that hospitalization. Three years ago, he suffered a blow to the
head while playing volleyball, lost consciousness for a few minutes but was not
seen by a physician. He has a history of his hands and feet "feeling puffy", so he
has been using his neighbor's furosemide for a couple of years to treat this
himself.
Habits: Smokes one half pack per day since the age of 20 and has not tried to quit.
Drinks one to two beer at dinnertime three to four times per week, but does not
drink hard liquor. Does not use street drugs.
Social History: Divorced 12 years ago. Works as a carpenter (self-employed). He
has one older brother who has had some hearing problems, but he has no details
about his brother’s condition. His parents are both alive and have had no serious
medical problems. He graduated from high school at age 18, and is happy in his
work.
What are the important problems that Mr. Mott is having?
Be specific.
What are the potential causes of these problems? What
aspects of his history might have contributed to the
problems that Mr. Mott is having?
What part(s) of the nervous system is(are) involved and
why?
What physical exam procedures are you going to perform
to test your hypotheses?
What are the important problems that Mr. Mott is having?
Be specific.
timing
• vertigo
• whistling
• episodic
• louder in left ear
• nausea/vomiting
• hearing loss – high frequency
What are the potential causes of these problems?
1.
stereocilia damage
– noise induced, aminoglycoside antibiotics
2. alcohol and tobacco
3. furosemide
4. toxins(?)
5. genetics
6. trauma
7. otosclerosis
8. Meniere’s disease
9. “other” neurological problem – tumour etc.
10. internal carotid artery (atherosclerosis)
11. high blood pressure
What part(s) of the nervous system is(are) involved and
why?
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semicircular canals
“auditory processing” center
vestibular nuclei
cochlea
cerebellum
middle ear
in common?
endolymphatic
duct?
What physical exam procedures are you going to perform
to test your hypotheses?
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Rinne/Weber
audiogram (whisper test, wristwatch)
neurological exam
otoscope
blood pressure
Physical Examination Findings
General Appearance
• Mr. Mott is a 46-year-old white male in no apparent distress.
Vital Signs
• Height = 198 cm; Weight = 89.3 kg Temperature = 37.0 °C (oral)
• Heart rate = 70 beats/min
• Blood pressure = 100/60 mmHg (Sitting)
• Respiratory rate = 14 breaths/min Oxygen saturation = 97%
Physical Examination Findings
(continued)
HEENT:
• Eyes: Pupils equal, round and reactive to light (PERRL), Extra ocular
movements intact (EOMI), no nystagmus and optical disks sharp.
• Neck: Trachea in midline. Thyroid normal size. No lymphadenopathy.
• Mouth: Oral mucous membranes pink and normal hydration.
• Ears: Tympanic membranes visualized and clear, pearly gray. Rinne test-normal
(air >bone) bilateral. Weber abnormal (lateralizes to right). Hearing loss with
marginal. Loss of speech discrimination. Unable to hear the tick of a watch in
both ears.
Lungs, cardiovascular, abdominal exam: Normal
Neurological exam: Normal with the exception of VIII (see above)
Near the end of the physical examination, Mr. Mott noted that the whistling in his
ears was increasing and he had a mild attack of spinning sensation. He felt
nauseated but did not vomit. During the attack, he developed a rightward
nystagmus. The spinning, whistling and nystagmus lasted about 10 minutes.
Identify the abnormal and pertinent normal findings on the
physical examination.
Abnormal:
no nystagmus  rightward nystagmus
Weber test  right
tinnitus
Normal:
BP
TM
Rinne
What are the potential causes of these problems?
1.
stereocilia damage
– noise induced, aminoglycoside antibiotics
2. alcohol and tobacco
3. furosemide
4. toxins(?)
5. genetics
6. trauma
7. otosclerosis
8. Meniere’s disease
9. “other” neurological problem – tumour etc.
10. internal carotid artery (atherosclerosis)
11. high blood pressure
Laboratory Results
Test
Results
Normal
WBC Count
Normal
Normal
Lyme disease antibody
titer
Negative
Negative
FTA-ABS (serum)
Nonreactive
Nonreactive
Na+
140 meQ/L
136-145 meQ/L
Cl-
100 meQ/L
95-105 meQ/L
K+
3 meQ/L
3.5-5 meQ/L
HCO3-
25 meQ/L
22-28 meQ/L
BUN
14 mg/dL
13-17 mg/dL
Creatinine
0.85 mg/dL
0.6-1.3 mg/dL (men)
Glucose (postprandial)
114
<140 mg/dL
Vitamin B12
720 ng/mL
190-900 ng/mL
Folate
8 ng/mL
2-10 ng/mL
Cholesterol (total)
188 mg/dL
<200 mg/dL
Audiometry
C
A
D
B