Unheard
Nervous System & Special Senses
0
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M76_F1.jpg"}},{"insert":"\n\nYou toss down a tablet of Ibuprofen and sip some water from your mug. Hopefully, this should reduce the thumping you feel inside your head. \n\n\u0022I\u0027m getting too old to stay up at night,\u0022 you think.\n\n\u201cHello doctor \u2013 your first patient has arrived,\u201d the receptionist cheerily announces. \n\nYou mutter an acknowledgement and ask for the patient to be sent in.\n"}]}
1
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M76_F2.jpg"}},{"insert":"\n\nYou are introduced you 18-year-old Nadiya, a university student. \u201cHello doctor \u2013 I\u2019ve come about my hearing,\u201d she says. You prompt her for more details.\n\n\u201cWell, I\u2019ve had trouble hearing people properly. I have to ask them to repeat themselves. In fact \u2013 I\u0027ve started relying on my friends\u0027 notes, because I can\u0027t hear the lecturers sometimes.\u201d\n\nYou ask her if she has any other symptoms. She thinks carefully and then replies:\n\n\u201cWell, I suppose I\u2019ve become clumsier in the last couple of months. Might be nothing really \u2013 I\u0027ve been feeling anxious since I\u0027m living on my own for the first time. It\u2019s funny though \u2013 I used to do gymnastics when I was a kid, but now I always seem to be knocking into something!\u201d\n\nYou glance at her medical records. She\u0027s been the picture of health, aside from an episode of chickenpox as an infant. You ask her if she\u0027s been ill in the recent past.\n\n\u201cI\u2019ve been completely fine, doctor \u2013 not even a flu or a stomach bug,\u0022 she responds.\n\nYou ask about her family history, and find out that that it is completely unremarkable. Both parents are in excellent health. There is no history of hearing impairment.\n"}]}
2
{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M76_F3.jpg"}},{"insert":"\n\nYou proceed to the examination. You measure Nadiya\u0027s height at 5\u20194\u201d (1.63 m) and her weight at 121 lbs (54.8 kg). Her vitals are stable. The general examination is unremarkable.\n\nOtoscopy shows no visible damage to the ear canal or tympanic membrane, and no significant obstructions or blockages. You then fetch a 512Hz tuning fork and explain that you\u2019re going to use it to perform some simple tests to narrow down the cause of her hearing problems.\n\nYou begin with Rinne\u2019s Test; you strike the fork against your knee to produce a sound before placing it first just a few centimetres away from Nadiya\u0027s ear, and then on the mastoid process. You do this for both ears. \n\nWhen you ask which position was louder, she answers that on both sides it was louder in the first position; however, the sounds only lasted for a short time. When she reports being no longer able to hear anything, you hold the fork up to your own ear and are still able to hear the sound clearly.\n\nYou note the results of the test down and move on to the Weber test. You strike the fork and place the base in the middle of Nadiya\u2019s forehead. She reports that the sound is equally loud on both sides.\n\nThe remainder of the systems examination is unremarkable.\n"}]}
3
{"ops":[{"insert":"Clearly Nadiya needs to be investigated further.\n\nWhich of the following investigations do you consider most important?\n"}]}
1. Audiometry
2. CT brain
3. MRI brain
5
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6
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7
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4
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