HPI: 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.” PMH: Mary takes ramipril for hypertension (HTN), a baby aspirin for cardio protection, and a statin for hypercholesterolemia. Vital signs are 120/88 P: 88 P02: 96% WT: 156 HT: 5’6″ ROS: Ask if Mary has had any exposure to ototoxic drugs or other otic damage in the past. Describe at least three. PE: What examinations will you perform on the ear? Describe the areas of the ear you will evaluate and what you will expect to find. You determine that Mary has a hearing deficit and tinnitus. What differential diagnoses do you want to consider? Describe at least three. What will your treatment plan for this patient be? What other recommendations

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:

Physical exam:

Diagnostic results: