Focused SOAP Note
Student’s Name
Institutional Affiliation
Course
Professor’s Name
Date
Focused SOAP Note
Patient Information:
M, 88, F, AA
S (subjective)
CC (chief complaint): My wife seems to be having trouble hearing me when I talk. She is turning the TV up loud.
HPI (history of present illness): Mary is an 88-year-old African American (AA) female married for 50 years to Albert. Albert complains that Mary cannot hear or hears but does not understand (especially in a group); turns up radio or television louder to hear (also noted by family, friends, and neighbors); Mary complains of tinnitus; and she feels like people are “mumbling.”
Current Medications:
Ramipril
Baby aspirin
Statin
Allergies: No known drug or food allergies.
PMHx: Mary takes ramipril for hypertension (HTN), a baby aspirin for cardio protection, and a statin for hypercholesterolemia.
Soc and Substance Hx: Lives with the husband Albert who complains the wife cannot hear television or radio and she need to increase the volume. No history of drug and alcohol abuse.
Fam Hx: Illnesses with possible genetic predisposition, contagious, or chronic illnesses. Reason for death of any deceased first-degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Mental Hx: No history of depression, anxiety, or suicidal ideation.
Violence Hx: No history of physical violence at home or in the neighborhood. No history of sexual violence.
Reproductive Hx: The 88-year-old patient is above reproductive age. Her last menstrual date is not known. She is married but it is not clear if she is sexually active.
ROS (review of symptoms):
GENERAL: No unintentional weight loss of gain, fatigue, fever, chills, and body weakness.
HEENT:
• Eyes: No visual loss, double vision, or blurred vision.
• Ears, Nose, Throat: No hearing loss, nasal congestion, or sore throat.
SKIN: No itching, bruises, or lesions.
CARDIOVASCULAR: No chest pain, discomfort, edema, or chest pressure.
RESPIRATORY: No coughing, sputum, or shortness of breath.
GASTROINTESTINAL: No nausea, diarrhea, or vomiting. No abdominal pain or blood in the stool.
GENITOURINARY: No burning sensation on urination. Last menstrual period date is unknown.
NEUROLOGICAL: No dizziness, tingling in the extremities, or headache. No changes in bowel or bladder control.
MUSCULOSKELETAL: No joint or muscle pain, or stiffness.
HEMATOLOGIC: No bleeding, bruising, or signs of anemia.
LYMPHATICS: No history of splenectomy or enlarged nodes.
PSYCHIATRIC: No history of mania, depression, or anxiety.
ENDOCRINOLOGIC: No history of sweating, polyuria or polydipsia.
REPRODUCTIVE: No history of recent pregnancy, vaginal discharge or sexual intercourse.
ALLERGIES: No history rhinitis, hives, or eczema.
O (objective)
Physical exam:
120/88 P: 88 P02: 96% WT: 156 HT: 5’6”
Diagnostic results:
Otoscopy- examination of external ear, wax in the ear can be easily visualized.
Rinne’s test to check hearing loss
Weber’s test – these are tests to find out type of hearing loss based on clinical examination.
Pure tone audiometry- I will also get patient’s audiometry done.
Visualization of ear by x-ray, CT scan to assess for any blockage.
A (assessment)
Differential diagnoses:
Wax in the ear – mostly causes conductive deafness. Tinnitus may or may not be present. Ear wax is normally secreted to protect the ear and it naturally cleanses itself. Accumulation of too much wax can affect the ear causing hearing difficulty (Di Stadio et al., 2018). Wax in the ear is the most common cause of conductive hearing loss.
Meniere’s disease- deafness, tinnitus, and vertigo is present. The condition causes a ringing sound in the ear. It makes individuals experience hearing difficulty (Hannigan et al., 2019). Some of the causes of the condition include stress, fatigue, emotional distress, pressure changes, and other health complications.
Cerebellopontine angle tumor- these tumors also present with deafness and tinnitus. The most common condition is vestibular schwannoma. One of the common symptoms is the sudden loss of hearing capacity. The growth may cause pressure on the ear nerves leading to hearing loss.
Otosclerosis – the patient could be at risk of otosclerosis. Additional diagnostic tests are necessary to avert health complications (Mkrtchyan et al., 2021). The condition involves the inability of the bone to vibrate to allow the ear to detect sounds.
P (plan)
The patient should start the medication to fight the bacterial infection that can cause hearing loss. Gentamicin 10ml BID is effective to clear the ear for hearing loss problems.
Amikacin 250 mg/ml is an antibacterial used to treat infections that can cause hearing loss. The patient should be observed due to side effects such as diarrhea, dizziness, and numbness (Mkrtchyan et al., 2021).
Streptomycin is effective for the treatment of hearing loss since it causes less ototoxicity compared to other drugs.
A practitioner will carry out a physical examination to determine if the wax in the ear is causing hearing loss (Weiss et al., 2020). The treatment will include removing the wax and checking if the patient can improve on the hearing ability.
Reflection.
I learned that different causes of hearing loss can affect patients at different ages. I learned that effective diagnosis and treatment of hearing loss is effective for recovery. The recovery will require follow-up to ensure improvement (Weiss et al., 2020). I learned that patients can experience hearing loss due to old age. Appropriate diagnosis and treatment are effective for recovery.
The patient should adhere to the treatment and come back to the clinic for two weeks. The husband should ensure the wife is taking the medication and monitor the improvement. In case the patient does not improve, a CT scan could be necessary to examine the cause of the hearing loss.
During the treatment, it is effective to provide information to the patient to obtain informed consent. The patient should receive treatment without discrimination. Justice is a core value in the administration of care (McDermott-Levy et al., 2018). Veracity involves telling the patient the truth to ensure they know about their illness and appropriate treatment. The patient should be informed about the risk factors of hearing loss and the side effects of the medication (McDermott-Levy et al., 2018).
During the treatment, it is vital to examine the risk factors that can cause hearing loss. Elderly patients with diabetes or high blood pressure are at risk of hearing loss. A heart condition, stroke, or brain injury can lead to hearing loss (Di Stadio et al., 2018). Collaboration with other healthcare workers is effective in the recovery of the patient.
The patient should avoid risk factors that can cause adverse health outcomes. For instance, loud noises such as television or radio can affect the patient. The patient should avoid exposure to dust which can affect the patient or cause accumulation of wax.
The patient should adhere to treatment and come back for evaluation after two weeks.
References
Di Stadio, A., Dipietro, L., Ricci, G., Della Volpe, A., Minni, A., Greco, A., … & Ralli, M. (2018). Hearing loss, tinnitus, hyperacusis, and diplacusis in professional musicians: A systematic review. International journal of environmental research and public health, 15(10), 2120.
Hannigan, I. P., Welgampola, M. S., & Watson, S. R. (2019). Dissociation of caloric and head impulse tests: a marker of Meniere’s disease. Journal of Neurology, 1-9.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Ethical principles and guidelines of global health nursing practice. Nursing outlook, 66(5), 473-481.
Mkrtchyan, N., Alciato, L., Kalamarides, M., Bernardeschi, D., Sterkers, O., Bernat, I., … & Lahlou, G. (2021). Hearing recovery after surgical resection of non-vestibular schwannoma cerebellopontine angle tumors. European Archives of Oto-Rhino-Laryngology, 1-10.
Weiss, R., Loth, A., Leinung, M., Balster, S., Hirth, D., Stöver, T., … & Kramer, S. (2020). A new adhesive bone conduction hearing system as a treatment option for transient hearing loss after middle ear surgery. European Archives of Oto-rhino-laryngology, 277(3), 751-759.
