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Toronto Notes 2019
Common Presenting Problems
Family Medicine FM33
Hearing Impairment
• seeOtolaryngology,OT7 Definition
• hearingimpairment:araisedhearingthresholdmeasuredasdecibelsofhearinglossrelativetothe normal population at specific frequencies
• hearingdisability:hearingimpairmentthatinterfereswithperformingdailytasks
Epidemiology
• prevalenceincreaseswithage(6%of35-44yrold,43%of65-84yrold)
• 90%ofage-relatedhearingloss(presbycusis)issensorineural
• hearinglossdetectablebyaudiologyispresentingreaterthan1/3ofpeople>65yr
Classification
• conductive(externalsounddoesnotreachthemiddleear)
• sensorineuralinvolvingtheinnerear,cochlea,orauditorynerve • mixed
Assessment
• infants:universalnewbornhearingscreeningprogram
• elderly:
■ whispered-voice test
• examinerstands0.6metrebehindthepatientandwhispersacombinationof6letters/numbersandasks
the patient to repeat the sequence; test 1 ear at a time with masking of the non-test ear ■ tuning fork test (to distinguish conductive from sensorineural hearing loss)
• RinneandWeber(notforgeneralscreening) ■ formal audiologic assessment
• puretone,air,andboneconductiontesting
• speechaudiometry
• impedanceaudiometry
Management
• counselaboutnoisecontrolandhearingprotectionprograms(GradeAevidence)
• performinvestigationsinpatientswithunexplainedsensorineuralhearingloss
■ blood sugar, CBC and differential, TSH, syphilis testing
■ consider a CT/MRI for patients with progressive asymmetric sensorineural hearing loss to exclude
vestibular schwannoma (acoustic neuroma)
• refer patients who
■ exhibit hearing loss for a complete audiological examination
■ have an unknown etiology to an ENT specialist
■ experience sudden sensorineural hearing loss to an ENT specialist (urgent, requires oral steroid Tx)
• treatment:hearingamplification(e.g.hearingaids),assistivelisteningdevices,andcochlearimplants can dramatically improve quality of life
Hypertension
Hypertension Guidelines are reviewed and updated annually, for up-to-date recommendations, please see http://guidelines.hypertension.ca/
Epidemiology
• 22%ofCanadianadultssufferfromHTN(prevalenceis52%inthe60-70agegroup)
• lifetimeriskofdevelopinghypertensionisapproximately90%
• 64%ofCanadianswhohaveHTNaretreatedandcontrolled,while17%areunawarethattheyhaveHTN • 3rdleadingriskfactorassociatedwithdeath
■ risk factor for CAD, CHF, cerebrovascular disease, renal failure, peripheral vascular disease
Definitions
• HTN
■ BP ≥140/90 mmHg (OBPM) or >135/85 (ABPM/AOBP) unless DM (≥130/80 mmHg), or age ≥80
yr (≥150/90 mmHg) • isolatedsystolicHTN
■ sBP ≥140 and dBP <90
■ associated with progressive reduction in vascular compliance ■ usually begins in 5th decade
• hypertensiveurgency
■ sBP >210 or dBP >120 with minimal or no target-organ damage
• hypertensiveemergency
■ severe HTN (dBP >120) + acute target-organ damage ■ accelerated HTN
Does this Patient have Hearing Impairment?
JAMA 2006;295:416-428
Purpose: To evaluate bedside clinical maneuvers used to evaluate the presence of hearing impairment.
Methods: Systematic review of original studies examining the accuracy or precision of screening questions and tests.
Results: 24 studies were included.
Conclusions: Elderly patients acknowledging a hearing impairment require audiometry, while those who indicate they do not have hearing impairment should be screened with a whispered voice-test.
A normal whispered voice-test requires no further workup, and those unable to perceive the whisper require audiometry. Weber and Rinne tests are not suitable for general hearing impairment screening.
Symptoms of HTN are usually NOT PRESENT (this is why it is called the “silent killer”).
May have occipital headache upon awakening or organ-specific complaints if advanced disease
Renovascular HTN Suspected if Patient Presenting with 2 or more of:
• Sudden onset or worsening of HTN and age
>55 or <30 yr
• Presence of abdominal bruit
• HTN resistant to 3 or more drugs
• Rise in Cr of 30% or more associated with
use of an ACEI or ARB
• Other atherosclerotic vascular disease,
particularly in patients who smoke or have
dyslipidemia
• Recurrent pulmonary edema associated
with hypertensive surges