SOLVED403

WESTON HOSPITAL 629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541 PATIENT: SIMONSON-WALKER, SIERRA ACCOUNT/EHR #: SIMOSI001 DATE: Attending Physician: Oscar R. Prader, MD S: Sierra Simonson-Walker, a 61-year-old woman, presented with left ear discharge with some bleeding. Sierra has a 4-year history of progressive hearing loss in the left ear. She denied any pain, numbness, or weakness. O: Upon examination, her right ear is within normal limits and the left ear canal is completely blocked with skin debris not consistent with cerumen. An attempt was made to remove the debris in the office, but the patient could not tolerate the severe discomfort. Medical History: Progressive hearing loss, no ear surgery, no reoccurring ear infections, no prolonged exposure to sun, no head and neck malignancies. Family History: Noncontributory Social History: The patient denies alcohol and tobacco use. Maximum conductive hearing loss on the left and normal hearing on the right is verified by the audiometry. CT scan showed opacification of the external ear canal with no evidence of bone erosion. The patient is admitted and taken to the operating room; the debris is visualized to be flaky and keratinaceous. A portion of this was traced back to the anterior portion
SCIENCE
HEALTH SCIENCE
NURSING

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