Focused SOAP Note Patient Information: MM, 88, Female, African American S (subjective) CC: “My wife has trouble hearing. She turns up the TV very loud when watching.” HPI: MM is an 88-year-old African American (AA) female who was brought to the clinic for a hearing problem.
Focused SOAP Note Patient Information: MM, 88, Female, African American S (subjective) CC: “My wife has trouble hearing. She turns up the TV very loud when watching.” HPI: MM is an 88-year-old African American (AA) female who was brought to the clinic for a hearing problem. The patient’s husband complains that MM does not hear him when he talks to her and turns the TV up so loud when watching. Associated symptoms include a feeling of people “mumbling” and tinnitus. She describes tinnitus as buzzing. Tinnitus worsens at bedtime. The patient has not stated the onset of trouble hearing. She has not reported any pain in the ear. Current Medications: She has a statin for hypercholesterolemia, baby aspirin for cardioprotection, and ramipril for hypertension (HTN). Allergies: No environmental, food, or medication allergies. PMHx: She received the Tdap vaccine 7 years ago. She received a PCV15 shot six months ago. She also received the covid-19 vaccine. No past major surgery. He has hypertension. Soc and Substance Hx: She is a retired banker. Denies using alcohol, tobacco, or any other substance abuse. She uses seat belts when in a car. She does not drive. She does not smoke. She has a strong support system comprising of her husband and children. She used to love gun shooting sport. Fam Hx: Her mother had hypertension and died aged 68 from ovarian cancer. Her Father died when she was young from a car accident. Her eldest son has type diabetes and hypertension. My maternal grandfather died of throat cancer and her paternal grandmother died of type two diabetes. Surgical Hx: No prior surgical procedures. Mental Hx: No history of self-harm practices. She was diagnosed with depression when she was 65. Violence Hx: No concerns about violence at home. No history of violence. Reproductive Hx: She is in a menopause state. Not pregnant and do not use contraceptives. She is not sexually active. ROS:
- GENERAL: No chills, fever, fatigue, or weight loss.
- HEENT: Eyes: No visual loss, double vision, or blurred vision. Ears, Nose, Throat: Complains of hearing loss. No congestion, sneezing, runny nose, or sore throat.
- SKIN: No rash or itching.
- CARDIOVASCULAR: No chest discomfort, pain, or pressure.
- RESPIRATORY: No sputum, shortness of breath, or cough.
- GASTROINTESTINAL: No vomiting, anorexia, diarrhea, or nausea.
- GENITOURINARY: No burning on urination.
- NEUROLOGICAL: No ataxia, headache, or dizziness.
- MUSCULOSKELETAL: No joint or muscle pain and stiffness.
- HEMATOLOGIC: No anemia.
- LYMPHATICS: No enlarged nodes.
- ENDOCRINOLOGIC: No polydipsia or reports of sweating, cold or heat intolerance.
- REPRODUCTIVE: Not sexually active.
- ALLERGIES: No history of, hives, asthma, rhinitis, or eczema.
- Vital signs: BP 120/88, P02: 96%, P 88, WT: 156 HT: 5’6”
- General: The patient appears her stated age. She is oriented to place, time, and people. She is well-groomed and hygienic. She answers questions correctly.
- Head: No scars or any abnormal features. The skull is of normal shape and size.
- Ears: Outer ear intact. No inflammation in the ear. No excess earwax. No injury to the inner ear. No abnormal ear bone growth.
- No spams in inner ear muscles.
- Cardiovascular: No chest cracks. Chest edema. Regular heartbeats or rates.
- Respiratory: No breathing distress. No fluids in the lungs. No wheezes.
- Audiometer test: The patient will wear earphones and be asked to hear words and sounds directed to each ear to find the quietest sound the patient can hear (van Beeck Calkoen et al., 2019). It is done by an audiologist.
- Tuning fork test: Kelly et al. (2018) noted that a tuning fork test can help a doctor detect hearing loss. The test can be used to identify where ear damage has occurred.
- Whisper test: A whisper test can be used by a doctor to evaluate patients’ ears for hearing. It identifies how well a patient hears and responds to words spoken at various volumes (O’Donovan et al., 2019).
- Blood test: Blood can be used to test for ear infections.
- Presbycusis: Presbycusis is the primary diagnosis for this case. Presbycusis is a hearing loss that occurs gradually as one ages (Wang & Puel, 2020). Symptoms of presbycusis include withdrawal from conversations, trouble hearing conversations, muffling sounds, difficulty understanding words and turning up the volume of radio or television (Wang & Puel, 2020). The patient experiences most of the symptoms making the presbycusis a primary diagnosis. The patient’s age also supports the diagnosis.
- Ear infection: Ear infection has been included in the diagnosis because it causes hearing loss and tinnitus (Venekamp et al., 2020). However, it has been ruled out because a physical exam shows no inflammation of the outer or inner ears.
- Muscle spasms in the inner ear: Muscle spasms can also result in hearing loss and tinnitus (Shi et al., 2019). This disorder can be ruled out because the physical exam showed no spams in the inner ear muscles.
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