Focused SOAP Note
Scholar’s Title
Institutional Affiliation
Course
Professor’s Title
Date
Focused SOAP Note
Affected person Data:
M, 88, F, AA
S (subjective)
CC (chief grievance): My wife seems to be having trouble hearing me after I speak. 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 bunch); turns up radio or tv louder to hear (additionally famous by household, pals, and neighbors); Mary complains of tinnitus; and she or he looks like individuals are “mumbling.”
Present Drugs:
Ramipril
Child aspirin
Statin
Allergy symptoms: 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 she or he want to improve the quantity. No historical past of drug and alcohol abuse.
Fam Hx: Diseases with doable genetic predisposition, contagious, or persistent sicknesses. Motive for dying of any deceased first-degree kinfolk ought to be included. Embrace dad and mom, grandparents, siblings, and youngsters. Embrace grandchildren if pertinent.
Surgical Hx: Prior surgical procedures.
Psychological Hx: No historical past of melancholy, anxiousness, 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 shouldn’t 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 strain.
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 modifications 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, melancholy, or anxiousness.
ENDOCRINOLOGIC: No historical past of sweating, polyuria or polydipsia.
REPRODUCTIVE: No historical past of latest 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 take a look at to verify hearing loss
Weber’s take a look at – these are checks to discover out sort of hearing loss based mostly on scientific examination.
Pure tone audiometry- I may also 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 – largely causes conductive deafness. Tinnitus could or could 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 most typical 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). A few of the causes of the situation embrace stress, fatigue, emotional misery, strain modifications, 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 widespread signs is the sudden lack of hearing capability. The expansion could trigger strain on the ear nerves main to hearing loss.
Otosclerosis – the affected person might be liable to otosclerosis. Further diagnostic checks are mandatory to avert well being issues (Mkrtchyan et al., 2021). The situation entails the lack of the bone to vibrate to permit the ear to detect sounds.
P (plan)
The affected person ought to begin the remedy to combat 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 unwanted effects similar to diarrhea, dizziness, and numbness (Mkrtchyan et al., 2021).
Streptomycin is efficient for the therapy 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 therapy will embrace eradicating the wax and checking if the affected person can enhance on the hearing capability.
Reflection.
I discovered that completely different causes of hearing loss can have an effect on sufferers at completely different ages. I discovered that efficient analysis and therapy 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 outdated age. Acceptable analysis and therapy are efficient for restoration.
The affected person ought to adhere to the therapy and are available again to the clinic for 2 weeks. The husband ought to make sure the wife is taking the remedy and monitor the advance. In case the affected person doesn’t enhance, a CT scan might be mandatory to look at the reason for the hearing loss.
Through the therapy, it’s efficient to present info to the affected person to acquire knowledgeable consent. The affected person ought to obtain therapy 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 applicable therapy. The affected person ought to be knowledgeable concerning the danger components of hearing loss and the unwanted effects of the remedy (McDermott-Levy et al., 2018).
Through the therapy, it’s critical to look at the danger components that may trigger hearing loss. Aged sufferers with diabetes or hypertension are liable 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 components that may trigger opposed well being outcomes. As an illustration, loud noises similar to tv or radio can have an effect on the affected person. The affected person ought to keep away from publicity to mud which may have an effect on the affected person or trigger accumulation of wax.
The affected person ought to adhere to therapy 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 checks: a marker of Meniere’s illness. Journal of Neurology, 1-9.
McDermott-Levy, R., Leffers, J., & Mayaka, J. (2018). Moral rules and tips of world well being nursing follow. 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 therapy choice for transient hearing loss after center ear surgical procedure. European Archives of Oto-rhino-laryngology, 277(three), 751-759.
