First Aid for the USMLE Step 2 CS

Section 4. Practice Cases

Case 17. 75-Year-Old Man with Hearing Loss

DOORWAY INFORMATION

Opening Scenario

Paul Stout, a 75-year-old male, comes to the office complaining of hearing loss.

Vital Signs

BP: 132/68 mm Hg Temp: 98.4°F (36.9°C)

RR: 18/minute HR: 84/minute, regular

Examinee Tasks

1. Take a focused history.

2. Perform a focused physical exam (do not perform rectal, genitourinary, or female breast exam).

3. Explain your clinical impression and workup plan to the patient.

4. Write the patient note after leaving the room.

Checklist/SP Sheet

Patient Description

Patient is a 75 yo M.

Notes for the SP

 Ask the examinee to speak up if he or she did not speak in a loud and clear manner.

 Pretend that you have difficulty hearing in both ears.

 On physical exam, demonstrate that you have no lateralization on the Weber test (ie, show that your hearing is equal in both ears).

 Pretend that you cannot hear when spoken to from behind.

Challenging Questions to Ask

“Do you think I am going deaf?”

Sample Examinee Response

“Your symptoms and the results of my exam show that you have some kind of hearing deficit. We need to perform more tests to figure out the cause of the problem, whether it is going to get worse, and whether we can halt its progression or improve your hearing. In the meantime, I would like you to stop taking aspirin.”

Examinee Checklist

Building the Doctor-Patient Relationship Entrance

 Examinee knocked on the door before entering.

 Examinee introduced self by name.

 Examinee identified his/her role or position.

 Examinee correctly used patient’s name.

 Examinee made eye contact with the SP.

Reflective Listening

 Examinee asked an open-ended question and actively listened to the response.

 Examinee asked the SP to list his/her concerns and listened to the response without interrupting.

 Examinee summarized the SP’s concerns, often using the SP’s own words.

Information Gathering

 Examinee elicited data efficiently and accurately.

Connecting with the Patient

 Examinee recognized the SP’s emotions and responded with PEARLS.

Physical Examination

 Examinee washed his/her hands.

 Examinee asked permission to start the exam.

 Examinee used respectful draping.

 Examinee did not repeat painful maneuvers.

Closure

 Examinee discussed initial diagnostic impressions.

 Examinee discussed initial management plans:

□ Follow-up tests.

 Examinee asked if the SP had any other questions or concerns.

Sample Closure

Mr. Stout, I know that you are concerned about your problem. I can confirm that you do have some hearing loss. I would like to run several tests, including some blood tests. I would also like you to stop taking aspirin, because this may be contributing to your hearing loss. I will refer you to an audiometrist, who will assess you for a hearing aid. Do you have any questions for me?

History

HPI: 75 yo M c/o bilateral hearing loss for all sounds that started 1 year ago and is progressively worsening. He had cerumen removal 1 month ago with moderate improvement. He reports occasional tinnitus and rare headaches. He notes that words sound jumbled in crowded places or when he is watching TV He denies inserting any foreign body into the ear canal. No ear pain, no ear discharge, no vertigo, no loss of balance. No history of trauma to the ears; no difficulty comprehending or locating the source of sounds.

ROS: Negative.

Allergies: Penicillin, causes rash.

Medications: HCTZ, aspirin (for 25 years).

PMH: Hypertension. UTI 1 year ago, treated with antibiotics.

PSH: None.

SH: No smoking, no EtOH, no illicit drugs. Retired veteran. Sexually active with wife only.

FH: No history of hearing loss.

Physical Examination

Patient is in no acute distress.

VS: WNL.

HEENT: NC/AT, PERRLA, EOMI, no nystagmus, no papilledema, no cerumen. TMs with light reflex, no stigmata of infection, no redness to ear canal, no tenderness of auricle or periauricle, no lymphadenopathy, oropharynx normal. Weber test without lateralization;Rinne test (revealed air conduction > bone conduction).

Chest: Clear breath sounds bilaterally.

Heart: RRR; S1/S2; no murmurs, rubs, or gallops.

Neuro: Cranial nerves: 2-12 grossly intact except for decreased hearing. Motor: Strength 5/5 throughout. DTRs: 2+ throughout. Sensation: Intact. Gait: Normal; no past pointing andheel to shin.

Differential Diagnosis

CASE DISCUSSION

Patient Note Differential Diagnoses

 Presbycusis: This is a process of the inner ear in which bone loss is greater than air loss, leading to a gradual loss of hearing. It is typically bilateral. Presbycusis is a common diagnosis as people age and can be detected by performing the Rinne test. Chronic hypertension can lead to vascular changes that reduce blood flow to the cochlea and can contribute to the development of presbycusis, as can other conditions that affect the vasculature, such as diabetes and smoking. This patient should be referred to an audiologist who works in conjunction with an ENT specialist. He will likely need a hearing aid.

 Cochlear nerve damage: The cochlear nerve can become damaged as a result of loud noise. This patient is a military veteran and admits to a history of exposure to loud noises. Cochlear nerve damage would present in a manner similar to presbycusis. As with presbycusis, patients with suspected damage should be referred to an audiologist working in conjunction with an ENT specialist. Such patients will likely need hearing aids as well.

 Otosclerosis: This is a disease of the elderly that presents as gradual hearing loss resulting from abnormal temporal bone growth. It is a conductive hearing loss, so air loss exceeds bone loss. Otosclerosis is usually bilateral, but in a minority of patients the disease can be unilateral or can affect one side more than the other.

Additional Differential Diagnoses

 Ménière's disease: This condition usually presents with hearing loss, tinnitus, and episodic vertigo. It is caused by endolymphatic disruption in the inner ear. Causes include head trauma and syphilis. It can be unilateral or bilateral.

 Ototoxicity: Hearing loss caused by antibiotics will become more pronounced and may even continue to worsen for a time after the drug is discontinued. Any sensorineural hearing loss associated with these drugs is permanent. Aspirin can also cause hearing loss, but such loss is reversible with discontinuation of the drug.

While workup is pending in this patient, aspirin should be withheld.

 Acoustic neuroma: It is unlikely that the patient has an intracranial lesion such as a brain tumor in the absence of any other signs. However, this diagnosis should be considered if evidence of focal neurologic deficits is found.

Diagnostic Workup

 Audiometry: To assess hearing function and deafness to specific frequencies.

 Tympanography: A graphic display that represents the conduction of sound in the middle ear. It may help distinguish middle ear from inner ear dysfunction.

 Brain stem auditory evoked potentials: Used to diagnose auditory neuropathy.

 CT—head: Used to rule out any intracranial process, tumor, bleed, or CVA. An MRI of the brain would be better for an acoustic neuroma or a schwannoma.

 VDRL/RPR: To rule out syphilis associated with Ménière’s disease.



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