You are an FY2 in a GP practice
Personal Details:
Name: Mr David Chen
Age: 50
Medical Record:
Past medical history: None.
Notes:
A 50-year-old man has presented with a 3-month history of hearing loss and tinnitus in both ears.
Task:
1. Talk to the patient, take a focused history, and address his concerns.
3. Discuss the management plan.
Opening Sentence: “Doctor, I’m worried about my hearing. It’s not as good as it used to be, and I’ve got this constant ringing sound in my ears.”
Open History (to give freely): “It’s been getting gradually worse over the last few months. It’s in both ears. I have to turn the TV up louder, and I sometimes miss what people are saying, especially in noisy places.”
I haven’t had any pain or dizziness. I just want to know what’s causing it and how to get rid of it.”
ICE (Ideas, Concerns, Expectations):
Ideas: “Is it just old age? Or could it be something serious?”
Concerns: “My main concern is the ringing. It’s driving me mad. I’m worried my hearing will keep getting worse.”
Expectation: “I want something to stop the ringing and get my hearing back to normal.”
How to Act: You are a sensible man who is frustrated and worried by your symptoms.
More History (only if asked):
You had a sensation of fullness in both ears that started at the same time. It also makes you feel like you are spinning.
You do not work in a noisy environment. You don’t listen to loud music. You are otherwise fit and well. The ringing is a high-pitched hiss, and it’s there all the time. It’s most noticeable when it’s quiet, like at night.
You haven’t had any pain, discharge or any infection-like features in your ear.
You haven’t had any limb weakness or change in sensation, no facial drooping, no speech problem.
Social History: Works as an accountant.
Questions to ask:
“So you can’t give me a pill to cure the tinnitus?”
Examination: External ear examination is normal with no features of infection (discharge), no blockage.
Bilateral medium-frequency sensorineural hearing loss.
Neurological examination: normal
History of Hearing Loss:
You mentioned your hearing has been getting worse. Is it in one ear or both?"
When did you first notice it?
How has it affected you day-to-day? Are you having to turn the TV up?
History of Tinnitus:
You described a ringing sound. Can you tell me more about it? Is it a ringing, buzzing, or hissing sound?"
Is it there all the time, or does it come and go?
Is there anything that makes it better or worse?
Red Flag Screening:
Have you had any sensation of fullness in your ears
Have you had any dizziness, especially a spinning sensation we call vertigo?
Have you had any pain in your ears or any discharge?
Have you had any weakness or numbness in your face?
Risk Factor Assessment:
Do you work in a noisy environment, or have you been exposed to loud noise in the past?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts about what could be causing this?
What is your biggest worry about these symptoms?
What were you hoping we could do for you today?
Explain the situation, the likely diagnosis or DD:
Thank you for coming in. It sounds like these symptoms are having a real impact on you. I’ve examined your ears, and there is no sign of infection or a blockage like earwax. I wonder if your symptoms suggest something called manières disease. This is a condition that affects the inner ear, and causes hearing loss, tinnitus and a fullness sensation in the ears.
Addressing and answering the patient’s ICE:
Ménière's disease is one of the conditions for which we don’t have a cure. However, symptoms can often be managed with treatment.
Treatment includes medicines to help with symptoms such as vertigo and hearing aids. There is also a treatment available for tinnitus.
The tinnitus, which is the ringing sound you’re hearing, is very often associated with this. It’s not a sound coming from the outside; it’s generated by the hearing pathways in the brain, often in response to a change in hearing.
Next Steps:
The first and most important step is to confirm the diagnosis and exclude the possibility of anything else.
I would recommend referring you urgently to a specialist. They will be able to offer further testing, including hearing checks, and decide the next step based on this assessment. •Lifestyle I don’t recommend trying any treatment for now until you see the specialist.
Although it is not a curative condition, I just want to reassure you that the symptoms are often very manageable, and people who have this condition manage to have a normal day-to-day routine with the right support.
If your symptoms are getting worse, causing pain, or if you have a discharge from your ears, please let us know urgently.
The key management step is a referral to ENT urgently for assessment and a hearing test. The candidate should explain the suspected condition and the suspected prognosis in a supportive but realistic approach.
What is scenario testing? This case tests the candidate’s ability to manage not uncommon presentations in general practice. It requires a clear explanation of a chronic condition, managing the patient’s expectations for a cure, and outlining a logical investigation and management pathway involving referral to another service (ENT).