Level 4 Case Study by 0N5A9q


									         Level 4 Case Study
 62yo Vietnam Veteran
 Level 2 Audiologic Evaluation reported
years of constant bilateral tinnitus, only
bothersome within last 4-5 months when
entering the VA system for the first time.
 Hearing was found to be normal,
 HHIE-S: 8 of 40 (mild handicap)
Seeking VA MH services for the first time
for possible PTSD.
Tinnitus Questionnaires Administered
              at Level 2
 Tinnitus and Hearing Survey:
  • Section A – 9
  • Section B – 4
  • Section C – 0
 Tinnitus Handicap Inventory: 38 (moderate
  subjective handicap)
 SMRT: 70/170
 Referred to Level 3 Educational Workshop
         Attendance at Level 3
 Active participant, identified “falling asleep”
  as his most bothersome tinnitus situation.
 Developed Sound Plan: music and a fan as
  both a soothing and background sound to
  help him fall asleep easier at night.
 Second workshop: not helping, only made him
  concentrate more on his tinnitus. Encouraged
  to keep trying and modifying sound plan over
  next several weeks.
     6 week follow up phone call
 Actively using his Sound Plan and trying a
  variety of sounds. Tried Deep Breathing and
  Imagery, wearing earbuds so as not to disturb
  his wife. Still struggling to find a Sound Plan
  that helps him fall asleep easier.
 “Not confident” in his ability to manage his
 Based on phone call, Level 4 Interdisciplinary
  Evaluation scheduled.
Level 4 Interdisciplinary Evaluation
 Re-administered Tinnitus Questionnaires:
     • Tinnitus and Hearing Survey
             Section A – 8
             Section B – 9
             Section C – 3
     • Tinnitus Handicap Inventory: 62 (severe subjective
       handicap) a +24 increase compared to Level 2
     • SMRT: 74/170, stable as compared to Level 2

 Accompanied by spouse
             Tinnitus Interview
 Loudness of tinnitus changes whenever
  "conscious" of it.
 Introducing other sounds makes tinnitus softer,
  but tinnitus seems even louder once sound is
  turned off.
 Tinnitus causes him to lose concentration, "drives
  me crazy“ mostly in left ear.
 Prior to PTM, for falling asleep he tried music
  (didn't help) talk radio during the day which helps
  (politics), and central A/C for sleeping, which
  helped a little.
       Tinnitus Interview, Cont.
• After developing sound plan at Level 3, he
  tried the same sounds with the same results.
  Deep breathing and imagery helped a little.
• He has a variety of stationary and portable
  devices to generate sound, including his
  iPhone which he already has loaded with
  pleasurable music that he uses at home and in
  the car. Some other devices he does own, but
  has not tried such as a box fan.
 Discussed at length with veteran and spouse
  the correlation of the timing of several
  sources of stress this past year and the
  increase in bothersome tinnitus.
   Recent move/life change
   Recent financial worries
   Actively seeking MH services for newly diagnosed
    PTSD; medication, therapy, and discussing these
    issues for the first time since Vietnam
        Assessment Plan, Cont.
• Developed a new Sound Plan for "getting back
  to sleep at night".
• Demonstrated the Sound Spa which he liked,
  particularly ocean waves.
• He does have a sound dock/radio for his
  iPhone and he will down load soothing ocean
  waves or other relaxing nature sounds. His
  wife thought this would not disturb her.
         Assessment/Plan Cont.
• He will also try his box fan which may help better
  than his Central A/C.
• He may also try interesting sounds in the form of
  Pontian music or talk radio.
• Also, tried the Resound Live TS demo device first in
  his left ear only, and he immediately noted less
  awareness of his tinnitus and liked it very much,
  although then the right ear tinnitus seemed louder.
  He preferred listening with both devices and wanted
  to try them during quiet times in order to relax.
        Fitting of Resound Alera TS
        combination instruments.
 One month later, veteran was fit with bilateral Resound
  Alera 61 TS Receiver in the Canal combination
  instruments, open domes.
 Activated TSG only and he was very pleased with
  instant “relief” from tinnitus.
 3 months later: doing well, wearing daily throughout
  the day. Wife notices less agitation while wearing
  devices. Even wears them in the middle of the night to
  help him fall back asleep if wakes up due to PTSD
  related issues.
 Satisfied and confident in tinnitus management.
 No further help needed or wanted.
• Level 4 Evaluation provided opportunity to
  revise Sound Plan and demonstrate new
  devices, after Level 3 education was
• Opportunity to discuss comorbid MH
  conditions as contributing factors (his MH
  provider was contacted for tinnitus
  interdisciplinary care)
• Including family members can be invaluable to
  tinnitus management

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