Archive for the ‘EENT’ Category
Chief-complaint: Sores in the mouth and tongue, swollen, tender and bleeding gums, painful red eyes
Western-diagnosis: Stomatitis and Conjunctivitis
Medical-history: 38 year old male. Generally very stressed, works long hours, eats junk food almost every day and is always feeling hungry. Has some abdominal discomfort after eating. Usually very thirsty but can’t drink a lot of liquid. Has an odd sleep routine. Is usually constipated and has occasional burning of urine.
Chief Complaint: Dizziness
Western Diagnosis: Meniere’s Disease
Medical History: 54 yo male with 15 year history of Meniere’s disease. Vertigo, tinnitus and hearing loss, vomiting when severe. Tried diuretics, salt restriction, conventional medications, all without benefit.
Questioning exam: Had not tried alternative methods. Has had recurrent severe episodes with increased severity. (Always has the basic symptoms, however).The frequency of severe attacks has steadily increased, from 1 per year to 6 this summer.Heat exacerbates the symptoms. He also has a feeling of fullness in his ears.
Chief Complaint: Ear pain and head ache
Western Diagnosis: Ear infection and fluid accumulation
Medical History: Lower back pain(dull), inability to get pregnant for 4 months, 2 miscariages in the past.
Questioning exam: Appetite is well, sleep is well, urination bowel all normal. No cold hands feet, very seldom dizzy especially after squatting.
Chief Complaint: Dizziness
Western Diagnosis: Vertigo
Medical History: Weight training 2x a week
Eats lots of fatty foods, sweet cravings
Drinks a lot of coffee
Questioning exam: Migraine headaches for 6 months
Chief Complaint: Tinnitus
Western Diagnosis: Tinnitus
Medical History: 43year old Caucasian male patient had an oral surgery on his left side of his jaw 5 weeks ago. Since then he was hearing high pitch ringing sound in his left ear. Patient was healthy until this condition. He also complains of tenderness around the surgical area, and also suffers from insomnia and depression since. Healthy diet and exercises regularly.
Questioning exam: Do you have insomnia because of pain or sounds? Sounds (tinnitus)
Any medications? Taking anti-anxiety medication and took antibiotics for 2weeks after the surgery.
Chief Complaint: Chronic headaches: Tension, sinus, and migraine headaches
Medical History: 29 year old female; occupation-Project Coordinator for a construction company.
States to condition of “chronic” headaches for past 6+ years. Suffering from three types of headaches: tension, sinus and migraine headaches. Wants to get off “so many” medications that many times don’t work.
Reports father diagnosed with cluster headaches.
Current medications: Advil and Aleve for tension H/A, Sudafed 12 hr. for sinus H/A (preventative), Amitryptaline, Midrin, Fioracet for migraine H/A, Orthonovum 1/35 oral contraceptive. Other history is unremarkable.
Chief Complaint: Headache
Western Diagnosis: Migraine-(dx. 02/96)
Medical History: 55 year old male, reports frontal and temporal unilateral headache, daily in the am for an hour and then in the evening.H x reveals that he has suffered from this kind of pain for approx. 15 years. worse: with light, in the evening and with stress. better: “nothing, makes it better. but i am still taking Imitrex” reports patient. overall H&P unremarkable.
Questioning exam: Energy is low, feels cold often, has chronic dull lumbar pain, chronic alternating diarrhea and constipation; poor sleep (4-6 hours, restless); urination normal.
Chief Complaint: Migraine Headache
Medical History: Ten year old male, complaining of migraine headaches which occur at any time of day. He had been having them since he was five years old. The H.A. would usually cause him to vomit. Prior to the onset of H.S he would see black spots, have ear ringing.
He would be very active while sleeping, kicking off the covers, tossing & turning. Red /purple color under the eyes (lower eyelid). He has a poor diet, very picky eater. Had problems in school.
Chief Complaint: migraines
Medical History: drinker & smoker
Questioning exam: dizziness
Pulse exam: large rapid wiry
Tongue exam: red no coat
OM Diagnosis: liver yang rising
Chief Complaint: tinnitus
Western Diagnosis: vestibular-cochlear outlet syndrome
Medical History: 27-year male c/o tinnitus in Left ear for years. Born with Right-sided deafness. Seen by MD’s (inc. Mayo clinic), Chiropractors with no resolution or result of any kind. Patient is otherwise healthy with no other complaints and is otherwise unremarkable.
Questioning exam: Tinnitus had a gradual onset that was not high-pitched. It only occurred in L side and progressed over a period of 6-8 years from an occasional nuisance to causing dizziness 1-2 times/week. There was no discharge. Patient had no preferences for warm or cold and did not exhibit any specific deficiency signs. No complaints of low back pain or nocturnal urination. No dry eyes, floaters, conjunctival injection. Dreams sleep was unremarkable. Patient lives with his fiance and has a healthy but not excessive sex life. No GI complaints. Eats well without any cravings. No constipation or diarrhea. No history of EPI prior to onset. Pt presented as otherwise unremarkable.