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 will reduce the thumping inside your head, and allow you to focus during the long day ahead in the neurology clinic. \n\n\u0022I\u0027m getting too old to stay up all night,\u0022 you think.\n\n\u201cDoctor\u2014your 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 to 18-year-old Nadiya, a university student. \u201cHello doctor, 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, doctor. I have to ask them to repeat themselves. In fact, I\u0027ve started relying on my friends\u0027 notes, because I can\u0027t hear the lecturers sometimes. I saw my family doctor and he organized a hearing test, which he said shows hearing loss.\u201d\n\nYou ask her if she has any other symptoms. She thinks carefully and then replies:\n\n\u201cWell, I guess I\u2019ve become clumsier in the last couple of months. Might be nothing really\u2014I\u0027ve been feeling anxious since I\u0027m living on my own for the first time. It\u2019s funny though\u2014I 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 has 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 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 including otoscopy and a skin exam is unremarkable.\n\nYou review the audiometry report (ordered by her family physician earlier), which reveals bilateral moderate sensorineural hearing loss. \n"}]}
3
{"ops":[{"insert":"Clearly Nadiya needs to be investigated further.\n\nWhich of the following investigations do you consider most important?\n"}]}
1. Lumbar puncture
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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