The case history is generally regarded in medicine as the “first test.” An accurate and thorough case history, when interpreted correctly, directs all necessary testing, which in turn helps to narrow the differential diagnosis. Clinical acumen, knowledge, and experience are essential to forming an accurate initial diagnostic interpretation of a patient’s condition. Although inexperienced clinicians are unlikely to misdiagnose cerumen impaction, they may fail to recognize, for example, that a patient who describes a Tullio phenomenon (sound-induced oscillopsia) may have a less common condition, such as superior semicircular canal dehiscence syndrome. Thus, although there is no fixed formula for obtaining a patient’s history that applies to all cases, a comprehensive and systematic approach to patient history-taking will greatly assist the clinician. The goal of the case history is to efficiently yet thoroughly extract the relevant patient background and details of his or her complaints in such a way that they can be appropriately interpreted. The background knowledge and clinical experience required to successfully diagnose the majority of pathologies on the basis of case history information are acquired through years of study and clinical practice. Therefore, this chapter is intended to outline several guidelines that can be used as part of a thorough approach to the patient case history. This chapter provides a format for encapsulating the process of gaining accurate information from patients and then synthesizing that information into a meaningful conclusion.
ELEMENTS OF THE CASE HISTORY
Demographic and Identifying Information
The information that is used to identify the patient within the clinic must be general enough to be interpreted by other clinics while maintaining necessary confidentiality. In addition to the patient’s legal name, other names used by this patient previously should be noted, including maiden names or aliases. Although a medical office or hospital will nearly always acquire social security identifiers for every patient, this information should be kept confidential and not be routinely included on all paperwork (the medical record number is more appropriate). Other identifying information that is required is straightforward: address, phone/TTY number, e-mail address, date of birth, medical insurance, and emergency contact information. In addition, information regarding the patient’s referral source is necessary so that medical correspondence can be sent to the referring source.
Chief Complaint
The principal symptom or complaint motivating the patient’s visit should be described by the patient with minimal prompting from the clinician or other care-givers, if possible. When appropriate, the chief presenting complaint is written verbatim. The chief complaint describes the single most compelling factor(s) that prompted the individual to seek medical evaluation. The chief complaint frames the patient’s concerns hierarchically, in that it is this complaint that the patient wishes to have explicitly addressed during the visit, rather than numerous other, less pressing complaints. Questions can be asked to clarify a symptom, such as, Is it only your right ear that is “ringing”?, but introducing possible related symptoms should be avoided in this section of the case history, to avoid unduly influencing patients (this is especially relevant for potential malingerers). As in most human interactions, there is a wide range of variability in how patients respond to the questioning of their chief complaint, and this inherent variability requires flexibility on the examiner’s part.
Onset
The timing of onset of symptoms is a critical piece of information for all cases; ideally, a screening process should provide a method by which relative emergencies (such as sudden sensorineural hearing loss) may be identified and promptly evaluated. Often the timing of onset alone may not reveal the seriousness of the pathology, if taken out of context, such as a sudden hearing loss that occurs without any apparent reason, in comparison with the sudden conductive hearing loss that can occur after bathing, if cerumen becomes waterlogged and subsequently impacted; therefore, it is imperative to determine not only the timing of onset, but any contextual factors that may be relevant. The general question format for this topic is, When did you first notice the problem? This simple question can lead to a complex answer. For example, in cases of delayed endolymphatic hydrops, the patient might report that hearing loss was first noticed a decade earlier, but that vertigo or other vestibular symptoms began quite recently within the past month. More commonly, patients with presbycusis or noise-induced hearing loss might report that they have not really noticed a problem at all, but that a family member insists that a hearing loss is present and recommends a hearing test. Also, when questioning patients regarding symptom onset, it is important to identify each germane symptom, as they can indicate widely differing pathologies. This symptom list includes (but is not limited to) discussions hearing loss, vertigo, imbalance, tinnitus, otalgia, aural pressure, facial weakness, and headache.
Time Course of Symptoms
It is crucial to document whether or not multiple symptoms are occurring either together or in sequence. For example, tinnitus may be high-pitched, constant, and nonlocalized in elderly patients who are experiencing insidious hearing loss, whereas Menière’s patients may describe low-pitched, intermittent, and unilateral tinnitus with bouts of sudden hearing loss and vertigo. Documenting the course of the symptoms is vital. A change in one’s tinnitus to a more pronounced intensity on one side with increased distortion might signal a progressive retrocochlear problem, such as a cerebellopontine angle tumor. Increasing duration or frequency of vertigo episodes for the patient with Menière’s disease might be associated with concurrent accelerated hearing deterioration. Every attempt should be made to confirm symptoms with objective measures. Tinnitus matching procedures can determine the approximate frequency and intensity of the symptom. Videonystagmography or traditional electronystagmography can record nystagmus in response to sound (Tullio phenomenon) or ear canal pressure change (known as Hennebert’s sign or a positive fistula test response). Acoustic reflex procedures can document middle-ear muscle spasm (tonic tensor tympani phenomenon) or absent stapedius muscle contraction in the case of otosclerosis.
Laterality of Symptoms
Hearing loss and tinnitus that are unilateral often (but not always) suggest a need for surgical treatment more frequently than bilateral conditions, with the exception of bilateral profound sensorineural hearing loss that is amenable to cochlear implantation or due to advanced neurofibromatosis type 2. Although challenging, imbalance and vertigo of peripheral origin can generally be attributed to an offending ear, especially in straightforward cases such as benign positional vertigo or uncomplicated Menière’s disease. Additional lateralizing symptoms, such as ear fullness or pressure, may help narrow the differential diagnosis as well as identify the side of vestibular loss. Mild symptoms should not necessarily be ignored. For example, unilateral tinnitus without significant hearing loss may not be alarming, but it can also be the presenting symptom of acoustic neuroma (more properly known as vestibular schwannoma).
Otologic Health History
Documentation of ear infections, otalgia, otorrhea, and otologic surgical history should include as much detail as possible. The number and frequency of confirmed bouts of otitis media with effusion (OME) can determine the need for pressure equalization tubes. If the hearing fluctuates, it is important to note what factors cause it to improve or worsen. Chronic tympanic membrane perforation, sometimes reported as otalgia and hearing loss during showering, as well as a history of chronic otorrhea, may require surgical treatment. Ear surgical history has implications for interpretation of test results and rehabilitation. Tympanoplasty with mastoidectomy may close an existing air-bone gap but will also lead to an enlarged mastoid cavity that results in abnormal physical volume test results and requires special consideration during earmold impression acquisition and hearing aid adjustment, given the subsequent changes in resonance that result from a mastoid defect.
General Health History
General medical history is important for several reasons. It is vital to identify broader health disorders that might affect hearing, such as diabetes or autoimmune disease. The clinician might introduce this area of questioning by asking “How is your overall health?” and allowing for a brief narrative in the patient’s words. In addition, specific questions regarding currently taken prescription and over-the-counter medications and known drug allergies should be listed. Immunizations given within the past five years should be documented. Mental health status and history of mental illness should be reported. History of hospitalization for any reason should be reiterated in this section where there is no apparent link to hospitalization for reasons related to hearing. The question Have others observed a change in your health recently? might offer a way of extracting this information. It is crucial to record pharmaceutical treatments that could damage hair cells, including treatment for certain cancers, tuberculosis, and life-threatening infections (see chapter 5). History of allergies may have implications for ear infections or vertigo attacks. Head injury can affect hearing in complicated ways, including concussion presenting as noise-induced hearing loss; perilymphatic fistula; ossicular damage; and facial, vestibular, or auditory nerve damage (see chap. 8). A complete review of systems, typically acquired by physicians, is a thorough and systematic way to review non-otologic health issues that may be pertinent.
Vestibular History
For the dizzy patient, a separate case history as an addendum to the primary case history is often necessary, given the exhaustive detail that is typically required. It is important to remember that dizzy patients are often quite debilitated, frustrated, and depressed, lending a quality of despair to many of their interactions. In this context, it is critically important to acquire an accurate, thorough history, as the history alone will often rule out many causes of dizziness. The initial goals of the audiologist and otolaryngologist in the evaluation of dizziness are to identify any neurological emergencies (e.g., stroke) that might warrant prompt evaluation; such cases are typically accompanied by other neurologic deficits and can be quite obvious, whereas other neurologic deficits can be more subtle (e.g., in the case of a posterior inferior cerebellar artery stroke, or Wallenberg’s stroke), particularly early in the course of disease. The next step is the separation between central nervous system causes of dizziness and peripheral otologic causes of dizziness. This distinction is crucial, because it will determine the proper treatment course for the patient in most cases. Otologic causes of dizziness can be unilateral (e.g., benign positional vertigo, Menière’s disease), bilateral (e.g., severe Menière’s disease, bilateral vestibular hypofunction) and frequently are difficult to diagnose without follow-up testing (e.g., superior semicircular dehiscence syndrome). Standard vestibular testing may include electronystagmography or videonystagmography, posturography, rotary chair testing, and vestibular evoked myogenic potential tests. Imaging studies, particularly magnetic resonance imaging tests, are often helpful as well. History acquisition should focus on the character of the symptoms (to differentiate vertigo from disequilibrium), the time course of episodes of dizziness (how long they last and how frequently they occur), inciting factors (such as dietary factors, positional changes, or loud sound), relieving factors (such as medication, resting), and previous treatments attempted. As mentioned earlier, other localizing nonvestibular symptoms (e.g., hearing loss, fullness, tinnitus, headache) can be helpful in identifying the problematic ear in unilateral cases or cases of vestibular migraine.
Headache
Headaches, particularly those of a migrainous nature, are commonly associated with dizziness. Hence, questions related to location and progression of the pain, duration, severity, and constancy may help to show a possible connection between migraine headaches and vestibular symptoms, if present. Aggravating stimuli such as dietary factors (e.g., caffeine, chocolate) and bright lights should be identified; it is well known that dietary modification alone can result in significant improvement in the majority of migraine-induced vestibulopathy. It is significant that not all migraine vestibulopathy has classic migraine headache symptoms, and that dizziness itself may be the most obvious symptom to the patient of underlying pathophysiology that is likely to be migrainous in nature.
Neurological Symptoms
To help determine whether a central neurological rather than peripheral origin to the complaint is suspected, a series of less obvious (to the patient) questions should be included. These should cover such topics as mood (depression/anxiety/despair), memory or concentration losses, history of seizures, speech and swallowing changes, history of sleep disorder, reduced energy level, muscle weakness, change in dexterity, and “tingling” sensations that may be indicative of neuropathies. Referral to a neurologist is clearly indicated when such symptoms are present.
Dietary Factors
The most common associations between diet and imbalance are those of Menière’s disease and migraine-induced vestibular dysfunction. In the case of Menière’s disease, a high salt intake is known to be a trigger for episodes of aural fullness, dizziness, or hearing loss. A patient suspected of Menière’s disease should have sodium levels estimated as accurately as possible, so that control over salt intake can proceed in a systematic fashion (<1500 mg/day of sodium is recommended for patients with Menière’s disease). In cases of migraine-induced vestibular dysfunction, there is a long and detailed list of dietary factors possibly associated with migraine headaches and, in some patients, dizziness or disequilibrium. It is important to assess whether a patient’s diet contains high levels of any known triggers (e.g., caffeine, chocolate), so that early identification of relevant dietary factors can be achieved. During treatment, patients will typically be asked to eliminate nearly all known migraine factors from their diet in order to determine whether a dietary trigger exists. Although compliance with this recommendation varies, it is essential to proper management and care of the patient with migraine vestibular dysfunction.
Genetic Hearing Loss
Like the vestibular questionnaire, this section may constitute an addendum to the primary case history. Alternatively, if a family history of hearing loss is evident, it is in the best interest of the patient and family to seek a genetic counselor for appropriate genetic testing. Such testing goes beyond mere curiosity, as it may be crucial in order to predict the likelihood of trait heritability in future offspring. This information can be initially screened with a series of questions such as: What family members have hearing loss? What is thought to have caused their hearing loss? At what age was their hearing loss noticed? How severe is their hearing loss? How was/is their hearing loss treated (hearing aids, etc.)? and the obvious question: Has genetic testing been done?
Amplification
Use of hearing aids or assistive technology and history of this use need to be detailed, including specific make/models and success with the various devices. This information has an obvious purpose of helping to determine further rehabilitative planning, but it also gives an accounting of hearing loss progression, which can indicate a need for an additional site of lesion testing.
Occupational/Military Hearing History
Aging and noise exposure are the two most common causes of permanent sensorineural hearing loss. Hearing loss caused by aging, or presbycusis (or presbyacusis), is suspected if the patient is in the sixth decade of life or older. Various conditions can cause premature presbycusis, such as diabetes and a variety of genetic factors. Noise exposure may confuse a diagnosis of presbycusis in a patient who is in his or her fifties. Similarly, degree of noise-induced hearing loss (NIHL) may be difficult to determine in elderly patients. Arriving at an accurate diagnosis for compensation cases and others, though difficult, is typically achieved by way of a noise history. Nonetheless, a thorough noise history will not define a degree of NIHL risk, because of variability of noise susceptibility across the human population. Eighty-five dBA exposure for an eight-hour work shift, which now serves as an “action level” for Occupational Safety and H...
