Consult - History and Phy.
Sample Name: Consult - Pulsatile Tinnitus
Description: Chronic headaches and pulsatile tinnitus.
(Medical Transcription Sample Report)
HISTORY: The patient is a 48-year-old female who was seen in consultation requested from Dr. X on 05/28/2008 regarding chronic headaches and pulsatile tinnitus. The patient reports she has been having daily headaches since 02/25/2008. She has been getting pulsations in the head with heartbeat sounds. Headaches are now averaging about three times per week. They are generally on the very top of the head according to the patient. Interestingly, she denies any previous significant history of headaches prior to this. There has been no nausea associated with the headaches. The patient does note that when she speaks on the phone, the left ear has "weird sounds." She feels a general fullness in the left ear. She does note pulsation sounds within that left ear only. This began on February 17th according to the patient. The patient reports that the ear pulsations began following an air flight to Iowa where she was visiting family. The patient does admit that the pulsations in the ears seem to be somewhat better over the past few weeks. Interestingly, there has been no significant drop or change in her hearing. She does report she has had dizzy episodes in the past with nausea, being off balance at times. It is not associated with the pulsations in the ear. She does admit the pulsations will tend to come and go and there had been periods where the pulsations have completely cleared in the ear. She is denying any vision changes. The headaches are listed as moderate to severe in intensity on average about three to four times per week. She has been taking Tylenol and Excedrin to try to control the headaches and that seems to be helping somewhat. The patient presents today for further workup, evaluation, and treatment of the above-listed symptoms.
REVIEW OF SYSTEMS:
GASTROINTESTINAL: Pertinent for nausea.
GENITOURINARY: The patient is noted to be a living kidney donor and has only one kidney.
NEUROLOGIC: History of dizziness and the headaches as listed above.
CONSTITUTIONAL: She has had an increased weight gain and fatigue over the past year.
PAST SURGICAL HISTORY: She has had a left nephrectomy, C-sections, mastoidectomy, laparoscopy, and T&A.
FAMILY HISTORY: Father, history of cancer, hypertension, and heart disease.
CURRENT MEDICATIONS: Tylenol, Excedrin, and she is on multivitamin and probiotic's.
ALLERGIES: She is allergic to codeine and penicillin.
SOCIAL HISTORY: She is married. She works at Eye Center as a receptionist. She denies tobacco at this time though she was a previous smoker, stopped four years ago, and she denies alcohol use.
VITAL SIGNS: Blood pressure 120/78, pulse 64 and regular, and the temperature is 97.4.
GENERAL: The patient is an alert, cooperative, well-developed 48-year-old female with a normal-sounding voice and good memory.
HEAD & FACE: Inspected with no scars, lesions or masses noted. Sinuses palpated and are normal. Salivary glands also palpated and are normal with no masses noted. The patient also has full facial function.
CARDIOVASCULAR: Heart regular rate and rhythm without murmur.
EYES: Extraocular muscles were tested and within normal limits.
EARS: There is an old mastoidectomy scar, left ear. The ear canals are clean and dry. Drums intact and mobile. Weber exam is midline. Grossly hearing is intact. Please note audiologist not available at today's visit for further audiologic evaluation.
NASAL: Reveals clear drainage. Deviated nasal septum to the left, listed as mild to moderate. Ostiomeatal complexes are patent and turbinates are healthy. There was no mass or neoplasm within the nasopharynx noted on fiberoptic nasopharyngoscopy. See fiberoptic nasopharyngoscopy separate exam.
ORAL: Oral cavity is normal with good moisture. Lips, teeth and gums are normal. Evaluation of the oropharynx reveals normal mucosa, normal palates, and posterior oropharynx. Examination of the larynx with a mirror reveals normal epiglottis, false and true vocal cords with good mobility of the cords. The nasopharynx was briefly examined by mirror with normal appearing mucosa, posterior choanae and eustachian tubes.
NECK: The neck was examined with normal appearance. Trachea in the midline. The thyroid was normal, nontender, with no palpable masses or adenopathy noted.
NEUROLOGIC: Cranial nerves II through XII evaluated and noted to be normal. Patient oriented times 3.
DERMATOLOGIC: Evaluation reveals no masses or lesions. Skin turgor is normal.
1. Pulsatile tinnitus, left ear with eustachian tube disorder as the etiology. Consider, also normal pressure hydrocephalus.
2. Recurrent headaches.
3. Deviated nasal septum.
4. Dizziness, again also consider possible Meniere disease.
RECOMMENDATIONS: I did recommend the patient begin a 2 g or less sodium diet. I have also ordered a carotid ultrasound study as part of the workup and evaluation. She has had a recent CAT scan of the brain though this was without contrast. It did reveal previous mastoidectomy, left temporal bone, but no other mass noted. I have started her on Nasacort AQ nasal spray one spray each nostril daily as this is eustachian tube related. Hearing protection devices should be used at all times as well. I did counsel the patient if she has any upcoming airplane trips to use nasal decongestant or topical nasal decongestant spray prior to boarding the plane, and also using the airplane ear plugs as these can be effective at helping to prevent eustachian tube issues. I am going to recheck her in three weeks. If the pulsatile tinnitus at that time is not clear, we have discussed other treatment options including myringotomy or ear tube placement, which could be done here in the office. She will be scheduled for a audio and tympanogram to be done as well prior to that procedure.
Keywords: consult - history and phy., chronic headaches, pulsatile tinnitus, eustachian tube disorder, fiberoptic nasopharyngoscopy, nasal decongestant, eustachian tubes, ear, headaches, pulsatile, tinnitus, pulsations,