You are on page 1of 5

Name of Patient: Joan Regala Hospital: DLSUMC OPD-ENT

Informant: patient and mother Department: ENT


Reliability: very good (90%) Preceptor: Ramon Ramos III, MD
Historian: Renz Marion M. Alemania Date Taken: June 13, 2017
Group No.: 7 Date Submitted: June 14, 2017

CLINICAL HISTORY

I. GENERAL DATA

J.R., a 13-year-old Filipino girl, single, Roman Catholic, right-handed, born in and residing at Brgy.
Emmanuel I, Dasmariñas Cavite, consulted for the first time in DLSUMC OPD on June 13, 2017 at 10:00 am.

II. CHIEF COMPLAINT

decreased hearing on the left ear

III. HISTORY OF PRESENT ILLNESS

The patient was apparently well until three months prior to consult when she experienced sudden-onset
itchiness of her left ear after swimming in a pool. The patient was relieved by the manipulation of the left ear by
a cotton tip. The symptoms disappeared with no accompanying fever, ear discharge, tragal tenderness and
tinnitus. The patient claimed to be well after the event.

A week prior to consult, the patient claimed gradual hearing loss on the left ear with no accompanying
symptoms.

Two days prior to consult, the patient experienced a recurrence of the itchiness and claimed watery
discharge from the left ear with unrecalled amount, color and consistency which woke her up from sleep. The
patient experiences aural fullness. Persistence of the itchiness prompted patient consult in our institution on June
13, 2017 at around 10:00 in the morning.

IV. PAST MEDICAL HISTORY

The patient had no previous history of hospitalizations, surgeries and previous illnesses. Her
immunization was undocumented, but the mother claims the patient had complete immunization from the health
center. The patient is not taking any medication or multivitamins.

V. PERSONAL AND SOCIAL HISTORY

The patient is fond of playing and reading books during her spare time. The patient was introduced to
gadgets at the age of 5. She spends around 1 to 2 hours playing her phone and watching television.

VI. FAMILY HISTORY

The family history of the patient was unremarkable.

VII. ENVIRONMENTAL HISTORY

The patient had no history of exposure to cigarette smoke or environmental pollutants. Garbage is
collected once a week but is not segregated. Drinking water comes from delivered mineral water and water for
daily use comes from the municipal water station.

VIII. REVIEW OF SYSTEMS

General: (-) weakness, (-) loss of appetite, (-) low-grade fever, (-) weight loss,
(-) easy fatigability
Integument: (-) wound, (-) rashes, (-) erythema, (-) pallor, (-) hyperpigmentation,
(-) hypopigmentation

1
Head and Neck: (-) stiffness, (-) headache, (-) dizziness, (-) mass, (-) swelling
Eyes: (-) pain, (-) redness, (-) discharge, (-) icteric sclera, (-) blurred vision
Ears: (-) otalgia, (-) vertigo
Nose and Sinuses: (-) watery discharge, (-) epistaxis, (-) obstruction, (-) colds
Mouth and Throat: (-) toothache, (-) hoarseness, (-) dysphagia, (-) ulcer, (-) sore throat
Respiratory: (-) cough, (-) dyspnea, (-) tachypnea, (-) hemoptysis,
(-) whitish phlegm, (-) pleuritic chest pain when coughing
Cardiovascular: (-) angina, (-) paroxysmal nocturnal dyspnea, (-) orthopnea,
(-) palpitations
GIT: (-) anorexia, (-) nausea, (-) vomiting, (-) abdominal distension
(-) diarrhea, (-) hematochezia, (-) change in bowel movement, (-) abdominal pain,
(-) retching, (-) melena, (-) constipation, (-) hematemesis, (-) heartburn
GUT: (-) incontinence, (-) frequency, (-) polyuria, (-) oliguria,
(-) nocturia, (-) flank pains, (-) mass
Hematologic: (-) easy bruising, (-) easy bleeding
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia, (-) cold intolerance,
(-) diaphoresis
MSS/Extremities: (-) fractures, (-) joint pains, (-) numbness, (-) paresthesia
Nervous: (-) seizures, (-) headaches

PHYSICAL EXAMINATION

I. GENERAL SURVEY

The patient is fairly-developed, fairly-nourished, conscious, coherent, oriented to time, place and person,
not in respiratory distress, ambulatory, and appears in her chronological age of 13.

VITAL SIGNS
BP: 120/80 mmHg
CR: 86 beats/min
PR: 98 beats/min
RR: 20 cycles/min
Temp: 36.5 ⁰C

II. SKIN

The patient was observed to have no pallor, jaundice and erythema. The skin is afrebile, returning
promptly after finger pressure, normal degree of pressure, and is soft and resilient. No primary or secondary
lesions are present. Skin appendages are unremarkable.

III. EYES

The patient has symmetrical eyes, with pink conjunctiva. Pupils have equal, bilateral reactivity to light.
Direct and consensual light reflex is present.

IV. CHEST AND LUNGS

The patient has symmetrical chest. There is symmetrical chest expansion with no use of accessory
muscles for respiration. There are no associated extra-pulmonary findings such as clubbing, facial puffiness and
prominent veins. There is resonance all over lung fields. Bronchovesicular sound predominates over all lung
fields. The patient has normal breath sounds, rate and depth. No adventitious sounds were heard.

V. CARDIOVASCULAR

There are no visible masses and lesions on the cardiothoracic wall. There is no precordial bulge. Cardiac
rate is normal at 86 beats per minute, with no heaves, thrills or murmurs. There is regular rhythm, S1>S2 at the
apex and S2>S1 at the base.

VII. GASTROINTESTINAL

There are no visible masses and lesions in the abdominal cavity. There were no direct and rebound
tenderness.

2
VIII. REPRODUCTIVE

The patient is Tanner Stage 2 on the breast examination with breast bud arising on the chest wall.

IX. NEUROLOGIC

CRANIAL NERVES

I : intact
II : (+) visual confrontation test
III : already assessed
IV, VI : intact
V : (+) facial sensation on ophthalmic, maxillary and mandibular regions
VII : able to perform eyebrow raising, shutting eyes tightly while trying to open them,
smiling, closing the mouth and puffing the cheeks
VIII : to be assessed later
IX, X : able to say “kakakaka”
XII : able to say “lalalala”
XI : not assessed

METAL STATUS

The patient has normal stream of thought appropriate for his age, able to communicate
well and fluently, with no auditory and visual hallucinations.

X. OTORHINOLARYNGOLOGIC EXAMINATION
(-) CLADS

There are no visible masses or lesions in the head and neck area. No cervical lymphadenopathies were
noted.
uvula is midline

erythematous vocal fold is symmetrical


tonsillar pillar

tongue is midline

The oral mucosa is pinkish. The right tonsillar pillar is erythematous with no exudates. Uvula and tongue
is midline. Indirect laryngoscopy reveals symmetrical vocal fold.

nasal septum midline

reddish turbinate

Anterior rhinoscopy reveals nasal septum is midline. Left inferior turbinate is reddish and enlarged.
Posterior rhinoscopy was unsuccessful due to the child’s gag reflex.

3
scanty cerumen
scanty cerumen

erythematous, erythematous,
bulging tympanic bulging tympanic
membrane membrane

WEBER’S TEST
Midline Weber

RINNE’S TEST
(+) Rinne, AU

SCHAWBACH’S TEST
Equal Schwabach

CASE DISCUSSION
DIAGNOSIS:
 Eustachian Tube Dysfunction, dilatory, AU
 t/c Acute Otitis Media with Effusion,mild, AU

BASIS FOR DIAGNOSIS:


 erythematous and bulging tympanic membrane
 (-) evidence of external ear canal infection and inflammation
 (+) middle ear inflammation
 (-) history of cough and colds.
 acute episode less than 3 weeks

DIFFERENTIAL DIAGNOSIS
 Meniere’s Disease
o sensation of fluctuating ear blockage with or without hearing loss
o (-) fluctuating course of the disease
 Temporomandibular Joint (TMJ)
o ear blockage symptoms
o (-) tragal tenderness, pain deep within the ear, headaches
 Acute Otitis Externa
o inflammation and signs of infection
o (-) erythematous, purulent ear canal

DISCUSSION AND TREATMENT

This is the case of patient JA, a 13-year-old Filipino female, who consulted for left ear pain. On history,
the patient presented with aural itchiness relieved by scratching and gradual hearing loss of almost 1 week in
duration. The patient claimed no history of cough and colds. On physical examination, the aural canal is patent,
with scanty cerumen, without purulent discharge, and with erythematous and bulging tympanic membrane.

The patient may have claimed a history of swimming a month prior to consult, but the physical
examination shows no proof of the existence of an acute otitis externa problem. Considering the bulging tympanic
membrane and erythematous middle ear, once may consider acute otitis media with effusion, since the ear canal
is free from any discharge. Because of the gradual hearing loss, one may consider a developing eustachian tube
dysfunction.

Acute otitis media is an inflammation of the middle ear within less than 3 weeks duration. AOM most
commonly affects children less than 3 years of age but is also prevalent across all age groups. Clinically, AOM
presents with otalgia and fever. However, in our case, the patient did not experience otalgia and fever, which
may be because of a still developing infection. AOM is divided into two – mild, and moderate or severe, which
depends on the presence of fever and severity on the visual analog scale.

4
However, because of the gradual hearing loss and ear fullness points to a dilatory dysfunction of the
eustachian tube. Patients complain of seemingly plugged ears. Because of the reddish right inferior turbinate,
the patient might have ear pressure or ear pain, causing ear clogging.

Treatment for AOM is outlined in the PSOHNS Clinical Practice Guidelines of December 2016. For mild
AOM like in our case, treatment is geared towards observation of the patient for 48 to 72 hours and note for
symptom improvement. If no improvement is noted, one may give Amoxicillin high dose at 80-90 mkd in 2 divided
doses. Failure to respond to Amoxicillin prompts shifting to Co-Amoxiclav (90mkd/6.4mkd) as the therapy.
Clindamycin (30 mkd TID) may be given for patients who are allergic to Penicillin. However, the cornerstone of
management is prevention and control of pain by providing analgesics like Paracetamol (10-15 mkd) and
Ibuprofen (5-10 mkd) for mild and moderate pain.

While addressing AOM in the patient, Eustachian tube dysfunction should also be addressed. However,
most treatments for Eustachian tube dysfunction are not done to humans but to animals instead. Therefore,
limited data exists on the efficacy of these treatments in Eustachian tube dysfunction. Dilatory dysfunction which
causes hearing loss are usually treated with nasal sprays which may act as decongestants, to treat presumptive
viral rhinosinusitis or allergic rhinitis. Politzer maneuver (insufflation of air in the middle ear through the nasal
cavity) can temporarily relieve the symptoms, but only provide short-term benefits.

Tympanostomy may be indicated in children with concurrent AOM with effusion. Tympanostomy provides
relief by neutralizing the negative pressure in the middle ear.

REFERENCES

Abes, et. al. Acute otitis media: current evidence-based recommendations for primary care physicians. Manila Otorhinolaryngological Foundation, Inc. Manila 2013.
PSOHNS. Clinical Practice Guidelines. December 2016.
Schilder AG, et. al. Eustachian tube dysfunction: consensus statement on definition, types, clinical presentation and diagnosis. Clin Otolaryngol 2015 Oct; 40(5):407-
11
Silman S. Efficacy of a modified Politzer apparatus in management of Eustachian tube dysfunction in adults. J Am Acad Audiol 10:496-501(1999)
van Heerbek N, et. al.Therapeutic improvement of Eustachian tube function: a review. Clin Otolaryngol Allied Sci 2002;27(1):50