Focused SOAP Note
Pupil’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Focused SOAP Note
Affected person Info:
M, 88, F, AA
S (subjective)
CC (chief criticism): My wife seems to be having trouble hearing me after I discuss. She is popping the TV up loud.
HPI (historical past of current sickness): Mary is an 88-year-old African American (AA) feminine married for 50 years to Albert. Albert complains that Mary can’t hear or hears however doesn’t perceive (particularly in a gaggle); turns up radio or tv louder to hear (additionally famous by household, associates, and neighbors); Mary complains of tinnitus; and he or she seems like persons are “mumbling.”
Present Drugs:
Ramipril
Child aspirin
Statin
Allergic reactions: No recognized drug or meals allergy symptoms.
PMHx: Mary takes ramipril for hypertension (HTN), a child aspirin for cardio safety, and a statin for hypercholesterolemia.
Soc and Substance Hx: Lives with the husband Albert who complains the wife can’t hear tv or radio and he or she want to improve the amount. No historical past of drug and alcohol abuse.
Fam Hx: Diseases with doable genetic predisposition, contagious, or power sicknesses. Cause for dying of any deceased first-degree kinfolk ought to be included. Embrace dad and mom, grandparents, siblings, and kids. Embrace grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No historical past of despair, nervousness, or suicidal ideation.
Violence Hx: No historical past of bodily violence at residence or within the neighborhood. No historical past of sexual violence.
Reproductive Hx: The 88-year-old affected person is above reproductive age. Her final menstrual date will not be recognized. She is married however it isn’t clear if she is sexually lively.
ROS (overview of signs):
GENERAL: No unintentional weight lack of acquire, fatigue, fever, chills, and physique weak point.
HEENT:
• Eyes: No visible loss, double imaginative and prescient, or blurred imaginative and prescient.
• Ears, Nostril, Throat: No hearing loss, nasal congestion, or sore throat.
SKIN: No itching, bruises, or lesions.
CARDIOVASCULAR: No chest ache, discomfort, edema, or chest stress.
RESPIRATORY: No coughing, sputum, or shortness of breath.
GASTROINTESTINAL: No nausea, diarrhea, or vomiting. No belly ache or blood within the stool.
GENITOURINARY: No burning sensation on urination. Final menstrual interval date is unknown.
NEUROLOGICAL: No dizziness, tingling within the extremities, or headache. No adjustments in bowel or bladder management.
MUSCULOSKELETAL: No joint or muscle ache, or stiffness.
HEMATOLOGIC: No bleeding, bruising, or indicators of anemia.
LYMPHATICS: No historical past of splenectomy or enlarged nodes.
PSYCHIATRIC: No historical past of mania, despair, or nervousness.
ENDOCRINOLOGIC: No historical past of sweating, polyuria or polydipsia.
REPRODUCTIVE: No historical past of current being pregnant, vaginal discharge or sexual activity.
ALLERGIES: No historical past rhinitis, hives, or eczema.
O (goal)
Bodily examination:
120/88 P: 88 P02: 96% WT: 156 HT: 5’6”
Diagnostic outcomes:
Otoscopy- examination of exterior ear, wax within the ear can be simply visualized.
Rinne’s check to examine hearing loss
Weber’s check – these are assessments to discover out sort of hearing loss based mostly on medical examination.
Pure tone audiometry- I can even get affected person’s audiometry completed.
Visualization of ear by x-ray, CT scan to assess for any blockage.
A (Assessment)
Differential diagnoses:
Wax within the ear – principally causes conductive deafness. Tinnitus might or might not be current. Ear wax is often secreted to shield the ear and it naturally cleanses itself. Accumulation of an excessive amount of wax can have an effect on the ear inflicting hearing issue (Di Stadio et al., 2018). Wax within the ear is the commonest reason behind conductive hearing loss.
Meniere’s disease- deafness, tinnitus, and vertigo is current. The situation causes a ringing sound within the ear. It makes people expertise hearing issue (Hannigan et al., 2019). Among the causes of the situation embrace stress, fatigue, emotional misery, stress adjustments, and different well being issues.
Cerebellopontine angle tumor- these tumors additionally current with deafness and tinnitus. The commonest situation is vestibular schwannoma. One of many frequent signs is the sudden lack of hearing capability. The expansion might trigger stress on the ear nerves main to hearing loss.
Otosclerosis – the affected person may be prone to otosclerosis. Extra diagnostic assessments are essential to avert well being issues (Mkrtchyan et al., 2021). The situation entails the lack of the bone to vibrate to enable the ear to detect sounds.
P (plan)
The affected person ought to begin the medicine to struggle the bacterial an infection that may trigger hearing loss. Gentamicin 10ml BID is efficient to clear the ear for hearing loss issues.
Amikacin 250 mg/ml is an antibacterial used to deal with infections that may trigger hearing loss. The affected person ought to be noticed due to unintended effects reminiscent of diarrhea, dizziness, and numbness (Mkrtchyan et al., 2021).
Streptomycin is efficient for the remedy of hearing loss because it causes much less ototoxicity in contrast to different medicine.
A practitioner will perform a bodily examination to decide if the wax within the ear is inflicting hearing loss (Weiss et al., 2020). The remedy will embrace eradicating the wax and checking if the affected person can enhance on the hearing skill.
Reflection.
I discovered that totally different causes of hearing loss can have an effect on sufferers at totally different ages. I discovered that efficient analysis and remedy of hearing loss is efficient for restoration. The restoration would require follow-up to guarantee enchancment (Weiss et al., 2020). I discovered that sufferers can expertise hearing loss due to previous age. Applicable analysis and remedy are efficient for restoration.
The affected person ought to adhere to the remedy and are available again to the clinic for 2 weeks. The husband ought to make sure the wife is taking the medicine and monitor the advance. In case the affected person doesn’t enhance, a CT scan may be essential to look at the reason for the hearing loss.
Through the remedy, it’s efficient to present info to the affected person to acquire knowledgeable consent. The affected person ought to obtain remedy with out discrimination. Justice is a core worth within the administration of care (McDermott-Levy et al., 2018). Veracity entails telling the affected person the reality to guarantee they find out about their sickness and acceptable remedy. The affected person ought to be knowledgeable concerning the danger elements of hearing loss and the unintended effects of the medicine (McDermott-Levy et al., 2018).
Through the remedy, it is important to look at the chance elements that may trigger hearing loss. Aged sufferers with diabetes or hypertension are prone to hearing loss. A coronary heart situation, stroke, or mind harm can lead to hearing loss (Di Stadio et al., 2018). Collaboration with different healthcare employees is efficient within the restoration of the affected person.
The affected person ought to keep away from danger elements that may trigger opposed well being outcomes. As an illustration, loud noises reminiscent of tv or radio can have an effect on the affected person. The affected person ought to keep away from publicity to mud which might have an effect on the affected person or trigger accumulation of wax.
The affected person ought to adhere to remedy and are available again for analysis 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 skilled musicians: A scientific overview. Worldwide journal of environmental analysis and public well being, 15(10), 2120.
Hannigan, I. P., Welgampola, M. S., & Watson, S. R. (2019). Dissociation of caloric and head impulse assessments: a marker of Meniere’s illness. Journal of Neurology, 1-9.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Moral rules and tips of worldwide well being nursing observe. Nursing outlook, 66(5), 473-481.
Mkrtchyan, N., Alciato, L., Kalamarides, M., Bernardeschi, D., Sterkers, O., Bernat, I., … & Lahlou, G. (2021). Hearing restoration 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 brand new adhesive bone conduction hearing system as a remedy possibility for transient hearing loss after center ear surgical procedure. European Archives of Oto-rhino-laryngology, 277(three), 751-759.
