GP- Revision Lecture 2020 GPSN Monash Practice Station

Julie’s Hearing loss

General Practice

Station No: 4
Station title: Julie Andrews
Time allowed: 8 min active time

Context:
● The consultation is set in a General Practice where the patient is seeing:
o A Junior Doctor under supervision with the examiner acting as your
supervisor. Do not interact with the examiner unless explicitly stated in the
candidate instructions.

Author & Date: Christina Kim May 3, 2020

Reviewed by & Date: Claire Harrison May 11, 2020
Reviewed by & Date:
Resources used to
develop the station RACGP
i.e. texts/ journals/ UptoDate
guidelines etc.
Keywords e.g.
discipline, presenting
Hearing Loss ENT Presbycusis
complaint, condition,
system, tasks, etc.
Used:

1
GP- Revision Lecture 2020 GPSN Monash Practice Station

CANDIDATE INSTRUCTIONS

Station No: 4
Station title: Julie Andrews
Time allowed: 4 minutes reading, 8 minutes active

You are a junior doctor working at a General Practice. Your next patient is Julie Andrews, an
83-year-old retired professional actress, singer, and performer.

Julie has presented today with some hearing loss.

She is up to date with relevant vaccinations. Recent blood tests to check renal function, liver
function, cholesterol profile and blood glucose have all been satisfactory.

Past medical history: Hypertension (well controlled – recent blood pressure 130/80 mmHg),
hyperlipidemia

Medications:
Lisinopril 5mg orally once daily, rosuvastatin orally 10mg once daily
No over-the-counter or complementary medications.
No allergies or drug intolerances.

Family history:
Brother had a heart attack aged 76.
Mother was diagnosed with breast cancer at age 65.

Social history:
Lives with her two dogs.
Non-smoker, no recreational drugs and doesn’t drink alcohol. Julie travels a lot as part of her
job and she continues to work part time as a lecturer at universities.

TASKS:
1. Please take a focused history to arrive at a diagnosis. When you have finished your
history, please scroll down for her examination findings and the results of an
audiogram (3 min)
2. Analyse and interpret these findings (1min)
3. Explain your diagnosis and your management plan to Julie (4 min)

IMPORTANT NOTES:

● You will NOT be prompted to move on to the next task and must manage your own time.

● Although the gender, age, ethnicity and other physical characteristics of the simulated patient may differ
to the description above, you should base your consultation on the information given.

2
GP- Revision Lecture 2020 GPSN Monash Practice Station

3
GP- Revision Lecture 2020 GPSN Monash Practice Station

SIMULATED PATIENT INSTRUCTIONS

Station No: 4
Station title: Julie Andrews
Time allowed: 4 minutes reading, 8 minutes active

Gender: Female
Age: 83
Ethnicity: English

Opening statement:
‘My daughter has been complaining that my hearing’s been bad.’

HOPC
W: over some years
W: bilateral
Q: hard to hear high frequency sounds and “s” and “ths”. Especially hard to hear at a party
Q: gradually getting worse
A: tried to clean out my ears – don’t think it is ear wax
A: nothing makes the hearing loss worse but loud noises really bother me more these days.
BICEE: If asked about what you think it is, you wonder if it could be wax – “maybe I have
jammed the wax up my ear canal!”. If asked about your concerns, you hope that you won’t
need a hearing aid like some of your friends. If asked about your expectations you wonder if
you could have your ears syringed today to see if that would resolve your symptoms.
Quatlity of Life (QoL) affected: Has been affecting her QoL since she can’t quite understand
all conversations.

No recent symptoms of a cold, no fever, no ear pain, no ear discharge

Sometimes some ringing in the ears.
Vertigo (sensation of the room spinning): None
Falls: None
Trauma: none
Excess noise exposure: has been around musical bands her whole life
Red flags: No to all of the following: Headache, changes to vision, facial numbness, changes
to sensation or weakness of face
No medications that may have damaged her ears – If asked no previous treatment with
gentamicin (type of antibiotic) – you are only on tablets for blood pressure and high
cholesterol and have been on them for years with no problems.

No other symptoms

You are up to date with relevant vaccinations. Recent blood tests to check kidney function,
liver function, cholesterol and blood sugar have all been satisfactory.

Past medical history: Hypertension (high blood pressure), hyperlipidemia (high cholesterol)

Medications:

4
GP- Revision Lecture 2020 GPSN Monash Practice Station

Lisinopril 5mg orally once daily (for blood pressure), rosuvastatin orally 10mg once daily (to
lower cholesterol)
No over-the-counter or complementary medications.
No allergies or drug intolerances.

Family history:
Brother had a heart attack aged 76.
Mother was diagnosed with breast cancer at age 65.
No family history of hearing loss if you are asked.

Social history:
Lives with your two dogs.
Non-smoker, no recreational drugs and you don’t drink alcohol. You travel a lot as part of
your job and you continue to work part time as a lecturer at universities.

5
GP- Revision Lecture 2020 GPSN Monash Practice Station

EXAMINATION FINDINGS – JULIE ANDREWS:

Inspection:
Pinna looks normal
External auditory canal normal with no wax or discharge and no tenderness on use of
auriscope
Tympanic membrane normal

Palpation:
No pain on moving pinna
No pre- or post-auricular lymphadenopathy

Special Tests:

Reduced hearing both sides on use of whisper test

Rinne positive bilaterally i.e. Air conduction > bone conduction both sides
Weber does not lateralize

AUDIOGRAM – JULIE ANDREWS

6
 GP- Revision Lecture 2020 GPSN Monash Practice Station

MARKING SCHEDULE

Station No: 4
Station title: Julie Andrews
Time allowed: 4 minutes reading, 8 minutes active

Done
Diagnosis Presbycusis- aka age related hearing loss
Knowledge Her friends have hearing loss but I thought I wouldn’t be in the same
category.
Attitude Not nice to know that I’m aging but tell me more.
Education Commonest cause of bilateral SND: Affects more than ½ of all adults by age
75 years.

High frequency hearing loss of advanced age (e.g. F and S not heard). Can be
accompanied by tinnitus and intolerance to very loud sounds.

With a high-frequency thresholds are greater than 40 dB on the audiogram, a

trial of hearing amplification is generally indicated.

Sensorineural pitch lost

Management Lifestyle: Avoid ongoing noise exposure

Hearing aid: getting fitted with hearing aids can ameliorate withdrawal,
depression, and emotional impact associated with presbycusis. Also leads to
QoL improvement.
ADRs of hearing aids: $$$, sometimes not well tolerated bc too much
cerumen produced which plugs the device, the meatus is too small; or the
device has increased static or noise. The aid may also cause discomfort, and it
is a cosmetic concern to many patients.

Cochlear implantation: not indicated for Julie at this point. Only for severely
affected pts where hearing aids are no longer effective.
placement of an electrode array within the inner ear to bypass the damaged
cochlea and stimulate the remaining cochlear neurons directly with electrical
stimulation

Auditory or aural rehab: teaches active listening, lip reading

- Additional to hearing aids

Strategies to manage tinnitus e.g. masking noises

Prevention Blood pressure and recent blood tests are fine
Breast screen- last check 1 year ago
FOBT
CST- last CST at age 65 – normal. No new sexual partners

7
 GP- Revision Lecture 2020 GPSN Monash Practice Station

Vx:
Flu Vx- received this year
Pneumococcal Vx- received at age 65
Herpes zoster Vx- received at age 70
Tetanus or pertussis with tetanus: booster every 10 years recommended

Information Pamphlet given

Repeat
Evaluate
Safety Net Follow up in 3 months.
Referral Refer to speech reading, Audiologist for hearing aid.

Domain and relevant content Clear fail Fail Inconclusive Pass Excellent
No attempt Poor Variable Overall an Exemplary
made, or a performance organisation and acceptable performance
very cursory with inconsistent performance with no errors
one significant demonstration of (includes or deficits.
errors or elements non-critical or
omissions: tolerable
deficiencies)
Communication Skills
- Introduces self and
explains role
- Good rapport
- Empathetic throughout
- Explains clearly without
medical jargon
- Explores ideas, concerns
and expectations
- Invites and appropriately
answers questions
History
- WWQQAA
- Probable cause Qs
- Excludes Red flags
- Diagnosis: Bilateral
sensorineural hearing
loss
- Mild at lower
frequencies, moderate
to moderate/severe at
increasingly lower
frequencies
- Most likely due to
presbycusis as both sides
affected and tends to
more affect higher
frequencies which is the
case here
- Better candidates may
explain the different
types of hearing loss and
why Julie’s presentation

8
 GP- Revision Lecture 2020 GPSN Monash Practice Station

aligns with sensorineural

loss
- Better candidates may
have elicited ideas,
concerns and
expectations, clearly
explains why symptoms
are not due to wax and
why syringing will not
help
-
Management
- D
- K
- A
- E
- M
- P
- I
- R
- E
- S