60 Year Female with left ear discharge, Hypertension
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I’ve been assigned this case as an intern in an attempt to understand the topic of ‘patient clinical data analysis’ to improve my competency in reading and comprehending the clinical data including history, clinical findings, investigations and come up with a diagnosis and the treatment plan.
CONSENT AND DE-IDENTIFICATION :
The patient and the attenders have been adequately informed about this documentation and privacy of the patient is entirely conserved. No identifiers shall be revealed throughout the piece of work whatsoever.
Presenting complaints:
HOPI:
Patient was apparently asymptomatic 1year back then she developed left ear discharge, insidious in onset, intermittent, mucoid type to mucopurulent occasionally foul smelling,non blood stained, aggravated on entry of water into ear and relieved temporarily with medication.she had about 4episodes /year each episode lasting for 2-3 days,last episode 6-10 days back.
H/o ringing sensation in left ear since 1year insidious in onset low pitch,low intensity not distributing sleep.
H/o decreased in left ear since 6 months insidious in onset non progressive non fluctuant more for soft sounds,able to maintain one to one conversation uses phone more with right ear
H/o left ear pain associated with discharge insidious in onset intermittent relives temporarily with medication radiating to head and neck.
H/o left aural fullness present
No h/o giddiness, facial weakness, swelling behind ear, diplopia,retroorbital pain.
No h/o high grade fever, projectile vomitings,blurred vision,altered sensorium,neck rigidity.
No h/o nasal obstruction,nasal discharge, paroxysmal sneezing, decreased perception of smell.
No h/o post nasal drip , facial heaviness.
No h/o thorat pain,pain during swallowing, difficulty in breathing, change in voice.
Past history:
N/K/C/o hypertension, diabetes mellitus type 2, asthma, Epilepsy,CAD,CVA, Thyroid disorders.
No h/O ENT surgeries in past
H/o hysterectomy 20years back.
Personal history:
Appetite normal
Sleep adequate
Bowels regular
Micturition normal
General physical examination:
Patient is conscious coherent and cooperative
PR: 84bpm
BP: 140/80 mm hg
RR: 18 cpm
No pallor, icterus, cyanosis, clubbing, lymphadenopathy, Edema
Systemic examination:
Cardiovascular System
- no thrills
- cardiac sounds S1 and S2 heard
- no cardiac murmurs
Respiratory System
- no dyspnea
- no wheeze
- tracheal position is central
- breath sounds : vesicular
- no adventitious sounds heard
Abdomen
- tenderness present (in the epigastric region)
- shape : scaphoid
- no scars, striae or engorged veins
- bowel sounds heard
- no bruits, rubs
- no shifting dullness
- no fluid thrill
- no palpable mass
- hernia orifices : normal
- liver: not palpable
- spleen : not palpable
CNS
- conscious
- normal speech
- cranial nerves
- motor and sensory systems normal
Diagnosis:
Left csom mucosal type
Severe left conductive hearing loss
Denovo hypertension
Treatment
Tab cinod 10 mg po/BD
Tab lasix 20 mg po/od
Keep ear dry
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