Transcript Pain Problem Case - University of Minnesota Duluth

Inner Ear Case
Mr. Rodney Mott is a 46-year-old carpenter, who has
trouble hearing and some problems with dizziness.
Med 6573: Nervous System
University of Minnesota Medical School Duluth
16 and 19 February 2007
Drs. Nordehn, Forbes & Fitzakerley
YOU MUST PREPARE PRIOR TO THE SESSION ON
FRIDAY, FEBRUARY 16 2007, 9:00 A.M.
1.
Review the information provided in this handout relative to Mr.
Mott’s present and past history, and your physical exam findings.
2.
•
Note significant data
•
Be prepared to discuss the case
Evaluate what you know about Mr. Mott relative to the “Questions
for Evaluating Hearing Loss” presented in the Isaacson and Vora
article “Differential Diagnosis and Treatment of Hearing Loss”.
3.
Answer the questions that are posed on slides 6 and 9 and be
prepared to discuss them.
History of Present Illness
• first noticed that he had trouble hearing his teakettle
o sometimes he hears whistling in his ears that is not the teakettle
o at other times, he can’t hear the kettle when it whistles
o this has been going on for several months, getting gradually worse in both
ears, although the sounds seem louder in his left ear
• about 3 months ago, while getting out of bed, he heard whistling in
his ears that became progressively louder - at the point where it
was becoming annoying, he suddenly felt the room spin
o sitting down gave him no relief
o he became nauseated and eventually vomited
o 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
o within one half hour the spinning had stopped and the whistling also
diminished
• he has had several similar episodes since then
o each begins with increasing whistling followed by the spinning sensation
• 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
o he remembers being told that the IV he was given contained antibiotics
• 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 “water pills" (furosemide?) for a couple
of years to treat this himself
Habits and Social History
Habits
• smokes one half pack per day since the age of 20 and has not tried
to quit
• drinks one to two beers at dinnertime three to four times per week,
but not 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?
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%
Lungs, CV, Abdomen: Normal
Neurological Exam: Normal with the exception of VIII (see next slide)
Physical Examination Findings
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.
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.
Audiometry
C
A
D
B
Otoacoustic
Emissions
Test
Interpret the procedural findings (audiometry,
radiology report and otoacoustic emissions) in the
context of Mr. Mott’s case.
What is your diagnosis?
Faculty Learning Issues
• Describe the components and physiology of the vestibuloocular reflex, and relate these components to the evaluation of
nystagmus.
• Distinguish among conductive and sensorineural hearing loss
and central auditory processing disorders. Define how each
type of hearing loss would alter the patient’s audiogram from
normal.
• Describe the physiological basis for and the interpretation of:
Rinne and Weber tests, audiometric testing, otoacoustic
emission and ABR testing.
• List risk factors for hearing loss and vertigo that should be
identified during history taking and/or evaluated during the
physical exam.