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First Patient: Tympanic Membrane Concern
The first patient appeared to the hospital complaining of temporary hearing loss and pain in the ear. The patient is 33-years old male. He said that he noticed the problem around one week ago when he returned from his scuba diving weekends. Except for hearing loss and pain in the ear, the patient reports hearing air coming out of the ear when he blows his nose, sense of water in the ear, and some pressure. It is the first similar concern with ears. That is why the patient looks nervous. No other complaints reported. The patient has not noticed any changes in body temperature or general well-being.
Concise Note for the First Patient
Chief complaint: Hearing loss, pain in the ear.
History of present illness: Patient experiences hearing loss, pain in the ear, sensation of water in the ear, and hears air coming out of the ear when blowing his nose. The patient noticed a problem when he returned from his scuba diving weekends. The pain in the ear and the related discomfort lasted for one week. The character of the pain is dull. It is worse after having a shower, especially when he has water in his ears. Once the ear gets dry, discomfort and pain fade away. The problem with hearing loss is temporary. There are no factors, which either worsen or improve them. The same is true about the rest of his symptoms such as sense of water in the ear and hearing air coming out if the ear when blowing the nose.
Surgical history: No past surgeries.
Family history: The patient is a single, 33-year old man without children. He has two elder brothers. Both parents are alive. No significant health concerns within a family.
Social history: The patient is from Ireland. His family moved to the United States when he was five years old. As for now, he is single. He lives alone in an apartment. The patient has a dog. Sometimes, he comes to his parents house to stay for weekends with his family.
Current medications: None.
Allergies: None.
Bad habits: The patient denies illicit drugs. He takes alcohol socially usually when he meets with his friends once a week or stays over at his parents home twice a month. The patient has never smoked.
Level of physical activity: The patient is actively involved in sports. He prefers surfing and scuba diving. During winters, when it is too cold to swim in the ocean, the patient exercises in the gym and swims in the pool. He always jogs in the mornings except for his surfing and scuba diving weekends.
Vital signs: The patient is full of energy even though a bit nervous because of his health concern. He looks healthy. Height 183 cm. Weight 80 kg. Normal BMI. B/P 120/80. HR 90 (normal). RR 16.
Physical examination: Primary attention was paid to ear examination. Audiometry showed that hearing loss is not severe. During the examination, it was discovered that the problem was with the tympanic membrane. Tympanic perforation was discovered while conducting otoscopy. The size of the perforation is around 1 mm in diameter. The motivation for assessing the size of membrane perforation is the fact that it might have a direct impact on the severity of hearing loss (Nahata et al., 2014). Most likely, the cause of the problem was barotrauma, i.e. sudden change of pressure between inner and outer surfaces of the tympanic membrane environment during scuba diving (Ibekwe, Nwaorgu, & Ijaduola, 2009). Conducting some laboratory tests with the aim of finding out whether there is a risk of ear infections because the patients ear was exposed to water both during weekends and after them is also recommended (Miyamoto, 2015).
Differential diagnosis: Tympanic membrane perforation is a primary diagnosis. No other diagnoses because all symptoms are common for this health concern. Also, no signs of ear infections detected.
Plan: Plan for care includes keeping ear dry and clean during healing. The emphasis should be made on avoiding swimming activities and being careful while having showers. Another point is to educate the patient on being careful during scuba diving and surfing with the aim of minimizing the risks of similar concerns in the future and on potential negative impacts of ignoring healing recommendations such as ear infections and further complications.
Second Patient: Thyroid Gland Case
The second patient appeared to the hospital with a complaint of insomnia and unexplained weight loss. This patient is a 60-years old woman. She said that she has noticed weight loss during the last three months even though she has not changed her diet and eating habits. In addition to it, she experiences fatigue and weakness together with depressive moods and heat intolerance. The patient states that she has a history of endocrine problems in her family, as her mother died of thyroid carcinoma. That is why she wants her thyroid gland checked.
Concise Note for the Second Patient
Chief complaint: Unexplained weight loss and insomnia.
History of present illness: Patient experiences insomnia and has noticed weight loss. She claims that the problems have lasted for almost three months already. Because the patient suffers from insomnia, she experiences fatigue and depression. She cannot fall asleep until 2 in the morning and wakes up not later that 7 oclock. Usually, she sleeps four to five hours. Depressive mood is worsened with recalling that her mother died of thyroid carcinoma. There are no factors, which would improve or worsen the symptoms. The patient has not changed her eating habits and has not taken new medications. She has not changed her lifestyle as well being actively involved in sports such as yoga and jogging.
Surgical history: No past surgeries except for dissecting out appendicitis at the age of 12 and being hospitalized for delivering a baby when she was 22 years old.
Family history: The patient is a 60-year old woman. She has a daughter. Her husband died two years ago. Primary health concern within a family is thyroid carcinoma, which became the cause of the patients mother death. Her father is still alive.
Social history: The patient is from Germany. Her family moved to the United States when she was ten years old. As for now, she is a widow because her husband died two years ago. She lives with a cat. However, the patient often comes to visit her daughter and grandchildren.
Current medications: None.
Allergies: None.
Bad habits: The patient denies illicit drugs. She takes alcohol socially when she comes to visit her family once a week. The patient has never smoked.
Level of physical activity: The patient goes in for yoga two times a week and jogs in the mornings the rest of the week.
Vital signs: The patient is full of energy even though a bit nervous because of her health concern and constant insomnia and fatigue. She looks healthy even though tired. Height 160 cm. Weight 55 kg. Normal BMI. B/P 110/60. HR 80 (normal). RR 16.
Physical examination: Primary attention was paid to neck examination with the aim of detecting thyroid nodules if any. The methods for examination were anterior (examining beneath sternocleidomastoid muscles) and posterior (neck near the clavicle). They imply pulping the patients neck to assess the size of thyroid gland and detect troubling signs if any. The patient was asked to swallow in order to improve the results of the testing (Mercado, 2014). During the examination, a thickening was discovered. The size of the nodule is about 3 cm in diameter. It is considered discrete. However, further laboratory tests and screenings are required to find out the nature of the problem.
Differential diagnosis: Because the patient reports insomnia, unexplained weight loss, and depression together with the nodule, the primary diagnosis is hyperthyroidism (University of Washington, n.d.). Still, ultrasound screenings and laboratory tests are recommended to find out whether the diagnosis is correct.
Plan: Plan for care includes conducting laboratory tests and screenings. Ultrasound screening of the thyroid gland and hormones tests are recommended with the aim of checking the levels of thyroid-stimulating hormone, thyroxine (T4), and triiodothyronine (T3). If thyroid gland fails to produce T3 and T4, i.e. their levels is low,it might prove that hyperthyroidism is the correct diagnosis (Jayakumar, 2011).
References
Ibekwe, T. S., Nwaorgu, O. G., & Ijaduola, T. G. (2009). Correlating the site of tympanic membrane perforation with hearing loss. BMC Ear, Nose, and Throat Disorders, 9(1). Web.
Jayakumar, R. V. (2011). Clinical approach to thyroid disease. The Journal of the Association of Physicians of India, 59(Suppl.), 11-13.
Mercado, J. C. (2014). Complete head and neck exam. Web.
Miyamoto, R. T. (2015). Traumatic perforation of the tympanic membrane. Web.
Nahata, V., Chandrakant, P. Y., Rashmo, P. K., Gattani, G., Disawal, A., & Amitava, R. (2014). Tympanic membrane perforation: Its correlation with hearing loss and frequency affected An analytical study. Indian Journal of Otology, 20(1), 10-15.
University of Washington. (n.d.). Patient history: Thyroid. Web.
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