Subjective Complaint: patient came to opd for consultation She reported that she was recently diagnosed with vertigo and hearing diminution with history of trauma 3 yrs ago. She states that in last 3 months her ears started to feel plugged. After one week of no changes she went to a phc clinic and was told she had wax in her ears which would go away on its own . About two weeks prior to opd consultation , she indicates having an episode of vertigo at walking , which started as “a really loud ringing noise and then the room started to spin”. She states that she needed to lie down and could not function for about 90 minutes.
She reports that since that incident, she’s had a constant feeling of her ears being plugged with difficulty hearing and mild dizziness. and about one week ago she get wax removal by ENT specialist She was diagnosed with vertigo and was rand possibly to get an MRI. She wanted a second opinion to possibly explain her symptoms, considering she’s never had any issues with her ears before.
Organs Affected: Both inner ears (affects hearing):
Symptoms: Ringing in the ears or tinnitus with bilateral hearing diminution
Symptoms: Vertigo or the tendency to fall and lose balance occurs during the last 3 weeks .
local examination: ear examination reveal
congested oedematous external canal with no wax or pus
normal tympanic membrane bilaterally
bilateral hearing deminution
patient was diagnosed as BPPV (Benign positional paroxysmal vertigo)
medical treatment :
patient receive treatment as Betaserc16mg tab +ear dros for otitis externa
Results: doctor decided to do MRI and her appointment with her ENT specialist. with in one week