A certain patient X was presented with a history of right ear fullness in the last few years. The issue then, was associated with a tympanic membrane retraction pocket that is filled with debris. The retraction pocket has undergone treatment in the past with several ear cleaning sessions having been undertaken. Having stopped the follow-up sessions, the patient presented again, this time with complaints of six months long continuous hearing loss of the right ear with increased aural fullness. Prior to this, the patient presents no history of trauma, surgery or draining ear. Furthermore, he also presents no other associated symptoms to his problem. Upon physical examination, the patient’s right ear exposed a superior retraction pocket full of white colored debris. The examination further revealed a lustrous white structure right behind the posterior of the tympanic membrane. The examination failed to note any drainage or perforation in the affected ear. Examination in the left ear showed that it was normal and as such, no further physical exam was required (Nasser, 2017).
A pure tone audiometry was performed and it revealed mild and near severe conductive hearing loss on the affected ear and revealed a slight sensorineural loss of hearing to the left ear, although at high frequencies. A CT scan of the temporal bones was also conducted and it showed that the right mastoid air cells were obliterated. It also showed a partially eroded septae with a complete erosion of the tegmen tympani. The patient then underwent a canal wall-up tympanomastoidectomy which revealed that the cholesteatoma sac was filling up the superior and posterior sides of the middle air, as well as the mastoid cavity. It also found out that the tegmen tympani was dehiscent and the incus eroded which caused a CSF leak that was covered with muscle, fat and fascia. Upon all these, a histopathology report revealed a cholesteatoma. The patient was diagnose with primary acquired cholesteatoma which is associated with the symptoms he was having. Since the patient was in the latter stages of the disease, it was recommended that he be taken under surgical management which includes atticotomy and simple mastoidectomy (Nasser, 2017).
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Health assessment 2
Patient Y is an 11 year old girl who has no past medical history that has come a long with symptoms suggesting she has hyperthyroidism (heat intolerance and weight loss). The patient has also been reported to have dropped in class performance. Both her grandmothers have experienced thyroid disease and are currently on thyroid replacement therapies. Upon admission, the clinician ordered thyroid function tests which included Free T4, T3, TSH, antithyroglobulin antibodies, anti-TSH receptor antibodies and antithyroid peroxide antibodies. The results confirmed the patient’s situation and diagnosed her to have hyperthyroidism with thyrotoxicosis disease. After diagnosis, the patient was immediately started on methimazole but the treatment was withdrawn within two weeks since she developed a severe reaction to it in the form of joint pains. She was introduced to another medication (Benadryl and Advil) which improved her symptoms but failed to improve the disease and as such, was recommended for a radio-iodine ablation with the use of Atenolol 50mg twice a day to which she became stable and was discharged home. The patient was seen after two weeks and the same tests were done which showed that she was free of the disease (Florea & Virji, 2017).
The tympanic membrane
The tympanic membrane is part of the human ear commonly referred to as the eardrum. The membrane is tasked with receiving sound vibrations from the outside and transmits them to the auditory ossicles which are located in the tympanic cavity. It separates the tympanic cavity from the auditory canal. The tympanic membrane plays a major role to the human body and as such, one should be able to tell with the help of a physician if this part of the body is normal or abnormal to play its function. A normal tympanic membrane should be pearly grey, shiny and near translucent. If in any case the membrane is seen to be red, then this means that it is infected, yellow means that one is having a glue ear and brown shows the presence of blood. The ear drum should either be bulging or retracted. The membrane should also be consistently smooth with a light reflection. A normal tympanic membrane should also have a short process with the malleus and umbo clearly visible. It is worthy of note that a physician should also be able to tell when a tympanic membrane is abnormal. This situation can be observed when eardrum has perforations, bubbles which are a sign of glue ear or resolving infection, white patches (cholesteatoma), red lesion at the tip of the malleus and granulations ( Www2.webster.edu , 2017).
Posterior and anterior thyroid examination
A thyroid examination is important since it is usually the first step towards the decision to diagnose thyroid diseases like Grave’s disease and Hashimoto’s thyroiditis. The palpation technique of examining the thyroid gland can be done in two ways: the posterior and anterior approaches. If using the posterior, approach, an examiner should have the patient sit in a comfortable position and ask them to slightly flex their neck forward like when they are looking at the ceiling. The examiner should stand behind the patient and place fingers of both hands on the patient’s neck in a position that places the index fingers just below the cricoid cartilage. The examiner should ask the patient to swallow water and in the process feel for the thyroid isthmus rising up under the fingers. The same process can be performed to examine both lobes. An examiner can also use the anterior approach where they come to the proximity of the patient from the front. The examiner can feel each lateral lobe by using the fingers of either hand to retract the sternocleidomastoid muscle in a posterior motion. They should use the fingers of the other hand to feel the thyroid by asking the patient to swallow water ( Www2.webster.edu , 2017).
SOAP note 1
Patient X was experiencing episodes of hearing loss, a situation that had gone on for a period of six months before seeking medical attention. The patient reported no other symptoms of the problem other than the fact that it was now a more serious situation than it was years before when he was taken under numerous ear cleaning sessions. After a physical examination of the problem, the superior retraction pocket was found to have debris and it was also observed that there was a white structure behind the posterior of the tympanic membrane. After further tests, the patient was diagnosed with primary cholesteatoma. The patient was scheduled for a surgery that included atticotomy and simple mastoidectomy. Follow up by the doctor was scheduled upon doctor patient discretion.
SOAP note 2
Patient Y is experiencing heat intolerance and weight loss, symptoms associated with the hyperthyroidism disease. She is also reported to have dropped in the class grading. After noticing the situation, her parents decide to take her for check-up. The patient is reported not to have experienced the situation although both her grandmothers were at the time of her admission under a thyroid gland replacement therapy. Tests by the doctor diagnosed the patient as having hyperthyroidism with thyrotoxicosis disease. The patient is immediately started on methmazole but the drug reacts with her body and results to joint pains and swelling. The patient is then introduced to another medication (Benadryl and Advil) which improved her symptoms but could not heal. The patient was then recommended for a radio-iodine ablation of her thyroid and placed on Atenolol 50mg twice a day upon which she was discharged. Her follow-up appointment in two weeks required another test of her thyroid with results coming out positive.
Appropriate laboratory tests
The purpose of laboratory tests is to make an accurate diagnosis of a situation and to manage disorders cost-effectively. Tests are usually done in patients that have subtle and unspecific symptoms that can only be determined by biochemical tests. In the case of thyroid disorders, tests including the serum concentrations of thyrotropin (TSH), thyroid hormones and anti-thyroid antibodies are done to determine the disease. The TSH test suits patient Y since it is the most effective for diagnosing primary hypo and hyperthydroidism. This is so because TSH secretion regulates, T3 (triiodothyronine) and T4 (thyroxine) which exert a negative log-linear feedback on pituitary thyrotrophs. As a result, mild changes in the concentration of free thyroid hormone (TH) leads to large changes in serum concentration of TSH hence making it suitable in evaluating thyroid function (Carvalho, Perez & Ward, 2013). For patient X, a special torch is usually used to assess cholesteatoma but in some cases, a doctor may refer the patient to an otolaryngologist who may run some tests including x-rays, MRIs or computed tomography (CT) scan. However, patient X can better be served by a test called audiogram since it is specialized for people who have affected hearing.
References
Www2.webster.edu (2017). ..:: The Tympanic Membrane ::.. .. Retrieved 15 June 2017, from http://www2.webster.edu/~davittdc/ear/tympanic/tympanic.htm
Carvalho, G., Perez, C., & Ward, L. (2013). Utilização dos testes de função tireoidiana na prática clínica. Arquivos Brasileiros De Endocrinologia & Metabologia , 57 (3), 193-204. http://dx.doi.org/10.1590/s0004-27302013000300005
Florea, A., & Virji, M. (2017). Case 537 --Endocrine Pathology Case . Path.upmc.edu . Retrieved 15 June 2017, from http://path.upmc.edu/cases/case537.html
Nasser, J. (2017). Case Presentation: . aub.edu.lb . Retrieved 15 June 2017, from http://staff.aub.edu.lb/~webotohn/downloads/cases/pac.pdf
