Medical Case Studies

Case Study 18-1: Medical Records

An electrical fire in the physicians' dictation room left a charred mass of burned and water-damaged medical records. Discharge charts had been stacked awaiting physician sign-off before they could be returned to Medical Records for storage. Several medical transcriptionists spent 3 days sorting through the remains to reassemble the charts, all of which were from the patients of the large otorhinolaryn-gology practice. In addition to patient identification information, the transcriptionists matched word cues to create piles of similar documents. Middle ear and inner ear patients were identified with words such as stapedectomy, tympanoplasty, myringotomy, cochlear, cholesteatoma, otosclerosis, labyrinth, otitis media, and acoustic neuroma. External ear patients were grouped using terms such as otoplasty, pinna, postauricular, and otitis externa. Mastoid, laryngeal, and nasal surgery patients were grouped separately. Restoring the charts was an impossible task, and the records were determined to be either incomplete or a total loss. The only document to survive the fire was an audiology report.

Case Study 18-2: Audiology Report

S.R., a 55-year-old man, was seen with the complaint of decreased hearing sensitivity in his left ear for the past 3 years. In addition to hearing loss, he was experiencing tinnitus and aural fullness. Pure tone test results revealed normal hearing sensitivity for the right ear and a moderate sensorineural hearing loss in the left ear. Speech thresholds were appropriate for the degree of hearing loss noted. Word recognition was excellent for the right ear and poor for the left ear when the signal was present at a suprathreshold level. Tympanograms were characterized by normal shape, amplitude, and peak pressure points bilaterally. The contralateral acoustic reflex was normal for the right ear but absent for the left ear at the frequencies tested (500 to 4000 Hz). The ipsilateral acoustic reflex was present with the probe in the right ear and absent with the probe in the left ear. Brainstem auditory evoked potentials (BAEP) were within normal range for the right ear. No repeatable response was observed from the left ear. A subsequent MRI showed a 1-cm acoustic neuroma.

Case Study 18-3: Phacoemulsification With Intraocular Lens Implant

W.S., a 68-year-old woman, was scheduled for surgery for a cataract and relief from "floaters," which she had noticed in her visual field since her surgery for a retinal detachment last year. She reported to the ambulatory surgery center an hour before her scheduled procedure. Before transfer to the operating room, she spoke with her ophthalmologist and reviewed the surgical plan. Her right eye was identified as the operative eye and it was marked with a "yes" and the surgeon's initials on the lid. She was given anesthetic drops in the right eye and an intravenous bolus of 2.0 mg of midazolam (Versed).

In the OR, W.S. and her operative eye were again identified by the surgeon, anesthetist, and nurses. After anesthesia and akinesia were achieved, the eye area was prepped and draped in sterile sheets. An operating microscope with video system was positioned over her eye. A 5-0 silk suture was placed through the superior rectus muscle to retract the eye. A lid speculum was placed to open the eye. A minimal conjunctival peritotomy was performed, and hemostasis was achieved with wet-field cautery. The anterior chamber was entered at the 10:30 o'clock position. A capsulotomy was performed after Healon was placed in the anterior chamber. Phacoemulsification was carried out without difficulty. The remaining cortex was removed by irrigation and aspiration.

Case Studies, continued

An intraocular lens (IOL) was placed into the posterior chamber. Miochol was injected to achieve papillary miosis, and the wound was closed with one 10-0 suture. Subconjunctival Celestone and Garamycin were injected. The lid speculum and retraction suture were removed. After application of Eserine and Bacitracin ointments, the eye was patched and a shield was applied. W.S. left the OR in good condition and was discharged to home 4 hours later.

CASE STUDY QUESTIONS

Multiple choice: Select the best answer and write the letter of your choice to the left of each number.

_ 1. The medical specialty of otorhinolaryngology is most often referred to as:

a. ENT or ear, nose, and throat b. optometry c. PERLA

d. oral surgery e. EENT/dental

_ 2. The surgery to remove one of the microscopic bones of the middle ear is a(n):

a. stapedectomy b. mastoidectomy c. myringotomy d. tympanoplasty e. otoplasty

_ 3. The procedure in question 2 may require construction of a new ear drum, a procedure called a(n):

a. otoplasty b. myringotomy c. stapes transfer d. tympanoplasty e. otoscope

_ 4. Mastoid surgery incisions are made postauricular, which is:

a. anterior to the ear drum b. over the left ear c. behind the ear d. inferior to the tympanic membrane e. between the ears

_ 5. The study of hearing is termed:

a. acousticology b. radio frequency c. light spectrum d. otology e. audiology

Case Studies, continued

_ 6. Sensorineural hearing loss results from:

a. damage to the second cranial nerve b. otitis media c. otosclerosis d. damage to the eighth cranial nerve e. stapedectomy

_ 7. Ultrasound destruction and aspiration of the lens is called:

a. catarectomy b. phacoemulsification c. stapedectomy d. radial keratotomy e. refraction

_ 8. The term akinesia means:

a. movement b. lack of sensation c. washing d. lack of movement e. incision

_ 9. The term that means "on the same side" is:

a. contralateral b. bilateral c. distal d. ventral e. ipsilateral

_ 10. Another name for an acoustic neuroma is:

a. macular degeneration b. neurilemoma c. otosclerosis d. labyrinthitis e. glaucoma

Write a term from the case studies with each of the following meanings:

11. record obtained by tympanometry _

12. pertaining to or perceived by the ear _

13. inflammation of the middle ear _

14. inflammation of the external ear _

15. physician who specializes in conditions of the eye _

16. within the eye _

17. abnormal contraction of the pupil _

18. generic drug name for Versed _

Case Studies, continued

Abbreviations. Define the following abbreviations:

22. IOL

Chapter 18 Crossword The Senses

Drags The Ear

ACROSS

DOWN

1.

Membranes that line the eyelids and cover the

1.

Coordinated movement of the eyes toward fixa-

fronts of the eyes

tion on the same point

6.

Sharpness of vision

2.

The middle layer of the eye

8.

A light-sensitive cell of the retina

3.

The tactile sense

12.

Lens implant: abbreviation

4.

Left ear: abbreviation

13.

Eye disorder caused by increased pressure

5.

Paralysis of the ciliary body:

14.

Pertaining to tears

a

16.

Inward deviation of the eye

7.

Iris: root

19.

Three: prefix

9.

Medical specialty treating the ear and throat:

abbreviation

10.

Tear, lacrimal apparatus: combining form

11.

Pertaining to the eye

15.

Nose: root

17.

Without correction: abbreviation

18.

Right eye: abbreviation

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Responses

  • Ginevra
    How to understand abbreviations in mecical case studies?
    6 years ago
  • rory
    How to write a case study using medical terms?
    5 years ago

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