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42 year-old male with no significant medical history presenting to ENT clinic after referral from PMD for perforated TM. Since then, the patient has not had any further ear pain or discharge but is left with persistent and constant hearing loss and ringing (high-pitched, non-pulsatile). AD: Decreased acuity to finger rub, EAC with some cerumen, cleared to reveal central perforation in posterior-superior quadrant of tympanic membrane. 36 year-old female with no significant medical history who presents after referral for voice hoarseness. 51 year-old female with a history of Hepatitis C, COPD and an 80 pack-year smoking history presents with concern about progressive voice hoarseness x2mo. Large volume abdominal ascites with a large amount of fluid extending into the bilateral inguinal canals. Renal failure in cirrhosis is associated with higher mortality both before and after transplant. Dilation of splanchnic arteries initially compensated by increased CO eventually decompensates with activation of mechanisms to preserve ECBV (RAAS, SNS, ADH) leading to fluid retention (ascites, edema) and renal failure due to intrarenal vasoconstriction.Bacterial translocation and the resulting inflammatory response may contribute to splanchnic vasodilation (through production of vasoactive factors like NO). The evaluation of suspected renal failure in patients with cirrhosis involves assessment of renal function for evidence of acute impairment, as well as analaysis of urine for protein or active sediment to suggest intrinsic renal disease (possibly warranting renal ultrasonography or biopsy). Renal failure in ESLD is due to the causes, complications or management of cirrhosis and has important implications, with HRS in particular offering the worst prognosis.5 Early recognition and management is critical to improving outcomes. 51yo AA male with hx DM, HTN, sarcoidosis presents with yellowing of eyes and full-body itching x3wks. Filling defect in the common bile duct with marked dilatation of the common duct and intrahepatic ducts. The patient is a 40yo male with a history of alcohol abuse, and seizure disorder secondary to traumatic brain injury who was admitted to this hospital 4d ago after an altercation with law enforcement officials. Moderate abdominal and pelvic ascites which has Hounsfield unit attenuation is greater than simple fluid suggestive of blood products.
Segment of bowel at the transition point has circumferential mural thickening and surrounding complex attenuation mesenteric fluid and mesenteric stranding. Palpation: place hand over patient’s groin (see figure), with two fingers each superior and inferior to the inguinal ligament.
GU: With a finger in the inguinal canal, bulges felt against the side of the examining finger are direct hernias, while those felt at the tip of the finger are indirect. Linea alba through weakened umbilical ring.Paraumbilical hernias through linea alba in the region of the umbilicus. Poor fascial healing possibly due to: infection (increased risk in wound dehiscence), obesity, smoking, immunosuppression excess wound tension, CT disorders. On the basis of 79 patients with cochlear hearing loss, the statistical distribution of two criteria commonly used in auditory brainstem response audiometry (ABR) was analyzed: the interaural V latency difference (ILD V) and the interaural difference of IN interpeak interval (ID I–V). References1.Brackmann DE, Selters WA (1982) Auditory brainstem response audiometry in acoustic tumor detection. JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. The patient last had normal hearing approximately 1yr ago when he noted acute onset of right ear pain, discharge, hearing loss and ringing in the setting of fever and a productive cough.

The patient describes a history suggestive of acute otitis media complicated by TM perforation. According to the patient, she underwent a C-section 3 months ago (at an outside hospital) complicated by bleeding requiring a second operation (L salpingoophorectomy); however, neither procedure required emergent intubation.
History and flexible nasolaryngoscopy consistent with trauma granulomata, as well as laryngopharyngeal reflux. She reports quitting smoking two months ago and is not sure if the hoarseness preceded or followed quitting. History concerning for malignancy, exam today shows significant laryngeal damage and vocal cord irregularities warranting further evaluation. Additionally, patients should be evaluated for evidence of bacterial infection including assessment of ascites if present as SBP produces a more severe form of the inflammatory vasodilation mechanism suspected to play a role in HRS. In the ED, the patient was found to have stable hemoglobin and creatinine and was discharged with urology follow-up after symptom resolution with catheter irrigation.
He states that his urine has been light pink in color, without clots, and significantly more clear than the prior 3 days.
Obstructive pattern along with only modest elevation of liver enzymes suggests the obstruction is likely extrahepatic which was supported by ERCP finding of a distal CBD stricture. Herniation typically occurs caudally (below arcuate line) due to absence of posterior rectus sheath.
He does not recall an inciting event (trauma, swimming) to this initial episode, and had no previous history of ear infections.
Persistent perforation seen on examination today can result in the tinnitus and hearing loss the patient complains of. She reports that she had some vomiting associated with anesthesia which ultimately required intubation and admission to the MICU for 5-6d. MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. He has had intermittent episodes of blood in his urine in the past, but never causing obstruction.
However, given the long-standing catheter, other considerations include trauma and infection. Patient has no history of prior instrumentation to cause iatrogenic stricture, and while sarcoidosis is associated with cholestatic complications (portal granulomas), pathology from biopsy showed papillary adenocarcinoma. No other significant injuries were found and the patient underwent CT imaging of head and c-spine, with notable findings of left occipital epidural hematoma, subarachnoid hemorrhage, but no significant midline shift.
The patient reported experiencing some abdominal pain since the altercation, but could not recall if he was hit in the abdomen.
This patient has no history of abdominal surgeries to suggest adhesions as a possible cause. By evaluating their standard deviations the percentages of statistical false-positives were estimated.
Raven Press, New York, pp 109–1172.Clemis JD, McGee T (1979) Brain stem electric response audiometry in the differential diagnosis of acoustic tumors. He saw his PMD several days later, was told he had a perforated ear drum and was treated with antibiotics.

However the marked sensorineural component remains unexplained, particularly given the patient reported previously normal hearing. She was discharged 10 days after the initial operation, and both she and her baby were in good health.
She otherwise denies difficulty or pain with swallowing, worsening shortness of breath, unintentional weight loss.
His catheter is managed at home with regular (q3wk) changes and no recent traumatic catheterizations. He states that this has not occurred in the past, and he does not have any prior history of post-prandial abdominal pain.
The patient was scheduled for surgery with a plan for initial laparoscopic survey of the abdomen followed by Whipple if no evidence of widespread disease. Neurosurgery was consulted and no emergent surgical intervention was required, the patient underwent serial imaging to monitor the bleed which was found to be stable and the patient slowly returned to baseline mental status.
While there is some evidence that acute otitis media can lead to sensorineural hearing loss, it is typically only mild and only in high-frequency ranges.1,2  Plan for further evaluation with repeat audiogram and MRI IAC, RTC when studies completed. Two weeks after discharge, she began experiencing throat irritation and 1 month after discharge she noticed voice hoarseness which has been persistent.
Will obtain UA, UCx, and schedule patient for cystoscopy with bilateral retrograde pyelogram. The patient was monitored for several days, continuing NGT to suction and with serial abdominal films. Also, educated patient on how to irrigate catheter if needed and provided ED precautions should obstruction persist despite irrigation attempts. However, abdominal pain persisted, abdominal radiographs showed worsening obstruction and the patient developed leukocytosis and on HOD7 the patient was taken to the OR for exploratory laparotomy. In a separate series of 301 unselected cases with asymmetric sensorineural hearing loss, 29 ABRs were suspect for retrocochlear pathology. Vasopressin, not octreotide, may be beneficial in the treatment of hepatorenal syndrome: a retrospective study. Upon entering the peritoneal cavity, there was obvious blood and very distended small bowel which was run distally with finding of a mesenteric laceration in the distal ileum which was walled off by omentum.
Radiographics : a review publication of the Radiological Society of North America, Inc, 21 Spec No, S261–71. Retrocochlear pathology could be confirmed in only 2 cases (both from the group with ABR present). Ultimately, a small bowel resection with primary anastomosis along with a repair of the splenic laceration was performed.

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