Patient Information
Age: 59. Sex: Female.
Subjective
Chief Complaint
“High-pitched noise in right ear mainly at night started two weeks ago.”
History of the Present Illness
The patient is 59 years old woman with a chief complaint of high-pitched noise in her right ear mainly at night. According to the patient, the symptom began two weeks ago. The right ear canal has cerumen impaction. The symptom may speak of tinnitus due to the earwax impaction, blood vessel condition, or aspirin intake. She has a past medical history of controlled essential hypertension and hypercholesterolemia. She denies chest pain during palpitations, sweating, losing hearing, or headaches. Physical examination is remarkable for negative nystagmus, negative Romberg equal, hearing bilateral, normal heart, and lungs.
The patient does not recall previous related diseases or surgeries. Water rinse at the right ear canal was performed to remove earwax, and a new appointment was planned in one week for reevaluation.
Medications
The patient has a past medical history of controlled essential hypertension and hypercholesterolemia, Benicar 20 mg tabs one po qd was proposed to treat high blood pressure. Rosuvastatin 40 mg tabs one po qd was proposed to reduce the level of low-density lipoprotein in the blood. The patient takes Aspirin 81 po qd.
Past Medical History
Allergies
No allergies were previously diagnosed.
Medication Intolerances
No medication intolerances were previously detected.
Chronic Illnesses/Major traumas
No chronic illnesses or major traumas were previously diagnosed.
Hospitalizations/Surgeries
No previous hospitalizations or surgeries.
The patient has never been told that she has Diabetes, HTN, peptic ulcer disease, asthma, lung disease, heart disease, cancer, TB, thyroid problems, or kidney disease or psychiatric diagnosis.
Family History
According to the patient, her mother, father, or siblings do not have any medical or psychiatric illnesses. Nobody among her relatives has been diagnosed with: lung disease, heart disease, HTN, cancer, TB, DM, or kidney disease.
Social History
The patient is a Master in Computer Science working as a database administrator in an office. She is married. Her husband is a teacher of Spanish at a university. The patient has no history of substance use/abuse, ETOH abuse, no smoking tobacco, or marijuana.
Review of Systems
General
The patient is healthy in appearance, no fatigue, chills, night sweats, no drop in energy level.
Cardiovascular
No chest pain, no edema noted, cardiovascular exploration is normal.
Skin
No rashes, bruising, bleeding or skin discolorations, any changes in lesions or moles.
Respiratory
No cough, wheezing, hemoptysis, dyspnea, pneumonia or TB.
Eyes
No corrective lenses, blurring, visual changes of any kind.
Gastrointestinal
No abdominal pain, N/V/D, constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stools.
Ears
High-pitched noise in the right ear, mainly at nights. No ear pain, hearing loss, discharge.
Genitourinary/Gynecological
No urgency, frequency burning, change in color of urine. No mammo, menstrual complaints, vaginal discharge.
Nose/Mouth/Throat
No sinus problems, dysphagia, nose bleeds or discharge, dental disease, hoarseness, throat pain.
Musculoskeletal
No pain, joint swelling, stiffness or pain, fracture hx, osteoporosis.
Breast
No SBE, lumps, bumps or changes.
Neurological
No syncope, seizures, transient paralysis, weakness, paresthesias, blackout spells.
Heme/Lymph/Endo
No HIV status, bruising, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.
Psychiatric
No depression, anxiety, sleeping difficulties, suicidal ideation/attempts.
Objective
Weight 164 lb. BMI 24.2. Temp 97.5 F oral. BP 130/80 mmHg, Height 5’ 9”. Pulse 62 bpm. Resp 14.
General Appearance
Healthy appearing adult female in no acute distress. Alert and oriented; answers questions appropriately. Shows no signs of hearing loss.
Skin
Skin is brown, warm, dry, clean, and intact. No rashes or lesions noted.
HEENT
Head is normocephalic, atraumatic, and without lesions; hair evenly distributed. Eyes: PERRLA. EOMs are intact. No conjunctival or scleral injection. Ears: Right ear has cerumen impaction, rinsed with water. Bilateral TMs pearly grey with positive light reflex; landmarks easily visualized. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Neck: Supple. Full ROM; no cervical lymphadenopathy; no occipital nodes. No thyromegaly or nodules. Oral mucosa pink and moist. The pharynx is nonerythematous and without exudate. Teeth are in good repair.
Cardiovascular
S1, S2 with regular rate and rhythm. No extra sounds, clicks, rubs, or murmurs. Capillary refill 2 seconds. Pulses 3+ throughout. No edema.
Respiratory
Symmetric chest wall. Respirations are regular and easy; lungs clear to auscultation bilaterally.
Gastrointestinal
BS is active in all four quadrants. Abdomen soft, non-tender. No hepatosplenomegaly.
Breast
Breast is free from masses or tenderness, no discharge, no dimpling, wrinkling, or discoloration of the skin.
Genitourinary
The bladder is non-distended; no CVA tenderness. External genitalia reveals coarse pubic hair in normal distribution; skin color is consistent with general pigmentation. No vulvar lesions noted. Well estrogenized. A small speculum was inserted; vaginal walls are pink and well rugated; no lesions noted. The cervix is pink and nulliparous. Scant clear to cloudy drainage present. On the bimanual exam, the cervix is firm. No CMT. The uterus is antevert and positioned behind a slightly distended bladder; no fullness, masses, or tenderness. No adnexal masses or tenderness. Ovaries are non-palpable.
Musculoskeletal
Full ROM is seen in all four extremities as the patient moved about the exam room.
Neurological
Speech clear. Good tone. Posture erect. Balance stable; gait normal.
Psychiatric
Alert and oriented. Dressed in clean slacks, shirt, and coat. Maintains eye contact. Speech is soft, though clear and of normal rate and cadence; answers questions appropriately.
Lab Tests
Feb 01, 2017, CBC Normal CMP Normal.
Total Cholesterol 120 mg /dl.
Triglycerides 135 mg/dl.
Electrocardiogram Sinus rhythm 60 per min, left axis deviation.
U/A Normal no proteinuria.
Medications taking.
Benicar 20 mg tabs, one po qd.
Rosuvastatin 40 mg tab One po qd.
Aspirin 81 mg po qd.
Diagnosis
Differential Diagnoses
- Tinnitus due to the cerumen impaction.
- Tinnitus due to the blood vessel condition.
- Tinnitus due to the aspirin intake.
Diagnosis
- Tinnitus due to the cerumen impaction
The patient complains of high-pitched noise in her right ear, mainly at night started two weeks ago. She claims that her mother, father, and siblings do not have any medical or psychiatric illnesses with similar symptoms what lessens the possibility of a contagious disease. According to the physical examination and detected symptoms, the patient might suffer from tinnitus due to the cerumen impaction, blood vessel condition, or aspirin intake. However, it is important to acknowledge the difference between the symptoms associated with these three conditions. Tinnitus is a common symptom of many diseases.
This fact creates hindrances to the correct treatment of the patient. Tinnitus can be caused not only by illnesses but also by continuous exposure to loud sounds, ETOH abuse, or drug abuse. Alcohol and drugs can lead to the appearance of high-pitched sounds in the absence of the source or intensify the existing tinnitus. Their effect tends to disappear when people become sober. The patient has no history of substance use/abuse, ETOH abuse, no smoking tobacco, or marijuana. She is alert and oriented.
The patient is dressed in clean slacks, a shirt, and a coat. She maintains eye contact. Her speech is soft, though clear, and of normal rate and cadence, she answers questions appropriately. The posture of the patient is erect, balance is stable, and gait is normal. Therefore, she cannot experience tinnitus due to alcohol or drug intoxication. People working with chainsaws, jackhammers, guns, or musical systems often hear high-pitched sounds even when the source is already absent.
War veterans often experience tinnitus as a result of a concussion. The relations between tinnitus and loud sounds are controversial. According to Serquera, Schlee, Pryss, Neff, & Langguth (2015), “overexposure to loud music can cause tinnitus, but musical stimulation at a well-adjusted loudness level can also be a key strategy for its treatment” (2).
Nevertheless, the patient denies the exposure to loud sounds preceding the appearance of the symptoms. The excessive amount of earwax in the ear can also lead to tinnitus. Physical examination revealed a cerumen impaction in the right ear of the patient. The ear was rinsed with water to wash the wax out.
Nevertheless, according to Zenner et al. (2015), “tinnitus is a frequent symptom, which, particularly in combination with comorbidities, can result in a severe disease-related burden” (p. 419). Therefore, all possible causes for the symptoms should be discussed for the correct treatment of the patient. The patient has a past medical history of controlled essential hypertension and hypercholesterolemia what can also influence her condition. Arterial hypertension is a common cause of pulsatile tinnitus. According to Kleinjung (2015), cardiac and respiratory sounds “may be heard “physiologically” only under conditions of major exertion, in association with increases in blood pressure, heart rate, and respiratory rate” (p. 163). Pathological changes may lead to the appearance of pulsatile tinnitus.
Nevertheless, the patient denies the pulsatile nature of high-pitched sounds in her right ear. The long-term use of aspirin can lead to the development of tinnitus. Topaz et al. (2016) claim that “aspirin studies support the social media data, with reports of up to 30 % of patients experiencing hearing problems with long-term aspirin use” (p. 249). Therefore, the intake of aspirin by the patient should be controlled in case of the development of the symptoms.
Plan/Therapeutics
Plan
- Carotid Doppler to see arterial patency.
- Electrocardiogram to compare.
- CBC to see WBC and hemoglobin.
- Holter 24H for rhythm.
Tinnitus cannot be treated independently of its main cause. There is no treatment efficient in the majority of cases. According to Wolever et al. (2015), “only 20% of patients who report tinnitus seek treatment, and when treated, most patients commonly receive sound-based and educational (SBE) therapy” (p. 1). The medication is hindered by the ambiguity of the main cause of the symptoms.
Langguth, Elgoyhen, & Schlee (2016) claim that “as the understanding of tinnitus pathophysiology is still incomplete and as there have not been serendipitous discoveries of pharmaceutical compounds that reliably reduce tinnitus intensity, no reliable targets for pharmaceutical treatment have yet been identified” (p. 251). New types of tinnitus treatment are developed to address both tinnitus and the diseases causing them. According to Maes et al. (2014), “specialized multidisciplinary tinnitus treatment based on cognitive behavioral therapy is cost-effective as compared with usual care” (795).
Therefore, the main cause of the symptoms should be defined for their effective treatment. In the present case, the cerumen impaction in the right ear of the patient was rinsed with water to eliminate the first possible cause of tinnitus. The planned treatment will address hypertension and hypercholesterolemia as further possible causes for the symptoms. Carotid Doppler will help to see arterial patency. Electrocardiogram will assess heart activity. CBC will help to see WBC and hemoglobin. Holter for 24 hours will assess rhythm.
Evaluation of patient encounter (Self-assessment)
This case makes me learn more about the various causes of tinnitus and different approaches to them. In my work with the patients who have tinnitus, I should pay attention to the fact that this is not a diagnosis but a symptom of some other disease or effect from ambient impact. I should assess all possible causes for tinnitus, including earwax impaction, alcohol or drug abuse, exposure to loud sounds, hypertension, and hypercholesterolemia.
I should remember that there is no universal treatment that will be effective in the majority of cases because the pathophysiology of tinnitus is not yet understood to the full extent. I should carefully choose pharmaceutical treatment in every case because the use of some medicaments such as aspirin can lead to the development of tinnitus. I should understand the ambivalent relations between tinnitus and various sounds. Loud noises can lead to the appearance of tinnitus, but leveled music may have a soothing effect. I can implement this approach according to the results of the physical examination.
References
Kleinjung, T. (2015). Pulsatile tinnitus. In D. M. Baguley & M. Fagelson (Eds.), Tinnitus: Clinical and research perspectives (pp. 163-180). San Diego, CA: Plural Publishing.
Langguth, B., Elgoyhen, A. B., & Schlee, W. (2016). Potassium channels as promising new targets for pharmacologic treatment of tinnitus: Can Internet-based ‘crowd sensing’ initiated by patients speed up the transition from bench to bedside? Expert Opinion on Therapeutic Targets, 20(3), pp. 251-254.
Maes, I. H., Cima, R. F., Anteunis, L. J., Scheijen, D. J., Baguley, D. M., El Refaie, A.,… & Joore, M. A. (2014). Cost-effectiveness of specialized treatment based on cognitive behavioral therapy versus usual care for tinnitus. Otology & Neurotology, 35(5), 787-795.
Serquera, J., Schlee, W., Pryss, R., Neff, P., & Langguth, B. (2015). Music technology for tinnitus treatment within tinnet. Audio Engineering Society Conference: 58th International Conference: Music Induced Hearing Disorders. 2015(2015), 2-3.
Topaz, M., Lai, K., Dhopeshwarkar, N., Seger, D. L., Sa’adon, R., Goss, F.,… & Zhou, L. (2016). Clinicians’ reports in electronic health records versus patients’ concerns in social media: A pilot study of adverse drug reactions of aspirin and atorvastatin. Drug Safety, 39(3), 241-250.
Wolever, R. Q., Price, R., Hazelton, A. G., Dmitrieva, N. O., Bechard, E. M., Shaffer, J. K., & Tucci, D. L. (2015). Complementary therapies for significant dysfunction from tinnitus: treatment review and potential for integrative medicine. Evidence-Based Complementary and Alternative Medicine, 2015 (2015), 1-8.
Zenner, H. P., Delb, W., Kröner-Herwig, B., Jäger, B., Peroz, I., Hesse, G.,… & Biesinger, E. (2015). On the interdisciplinary S3 guidelines for the treatment of chronic idiopathic tinnitus. HNO, 63(6), 419-427.