Focused SOAP Note

Assignment: Assessing, Diagnosing, and Treating Head, Neck, and Face Disorders

Focused SOAP Note

Patient Information: 

Initials: M Age: 88 Sex: Female Race: African American

S  Hearing problem

CC (chief complaint): The patient comes to the hospital complaining of having trouble with hearing. She has to tune the television up loud so she can hear.

HPI (history of present illness):  The patient Mary, is 88 years old African American female who has been married for 50 years to her husband Albert. According to her husband, Mary cannot hear, or even when she hears, she may not understand, especially when in a group.  Mary has to turn up the radio or the television louder than normal to hear. This action was also noted by her family members, neighbors, and friends. Mary complains of tinnitus and often feels like people are 'mumbling'

Current Medications: She takes Ramipril for hypertension (HTN), a statin for hypercholesterolemia, and baby aspirin for cardioprotection (Steyger, 2017).

Allergies:  Patient does not report any form of allergy.

PMHx:  There was not reported

Soc and Substance Hx:  Lives with husband for 50 years. No reports of drug or substance abuse. 

Fam Hx: Patient has a history of Hypertension, No report for family members documented. 

Surgical Hx: Patient has not surgical experience. 

Mental Hx: Does not report any form of depression or mental health issues. 

Violence Hx: Does not have any related history of violence to herself or those around her. 

Reproductive Hx: Patient is not sexually active. 

ROS (review of symptoms): 

GENERAL: No weight loss, fever, chills, weakness, or fatigue.

HEENT: 

• Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. 
• Ears- Complains of Hearing loss; Nose, Throat: No sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: Blood pressure. No palpitations or edema.

RESPIRATORY: The patient reports no signs of shortness of breath, does not suffer from any cough or hemoptysis. 

CARDIOVASCULAR:  Patient does not suffer from any form of tachycardia or chest pain. There is not sign of paroxysmal nocturnal dyspnoea or orthopnoea. 

GASTROINTESTINAL:  Patient dose not suffer from any form of abnormal discomfort or pain. Denies nausea, flatulence, diarrhoea or vomiting. 

GENITOURINARY:  Patient denies dysuria, haematuria or change in the frequency of urination. Denies difficulty in beginning or stopping streams of incontinence and urine. 

MUSCOSKELETAL:  Patient denies pain or falls. Patient denies evidence of hearing a snapping or clicking sound. 

SKIN:  Patient reports not change of coloration like Jaundice or cyanosis, pruritus and no rashes. 

O (objective)

Physical exam: 

Vital Signs: 120/88 P: 88 P02: 96% WT: 156 HT: 5’6”

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Hearing Loss Audiometry 

This test is going to entail the use of an audiometer in measuring the threshold of hearing by bone conduction and air tests. Conductive hearing loss is often present when there is an elevation of air conduction threshold which is often elevated while the bone conduction remains normal (Dobie, 2018). A sensorineural hearing loss will happen if the bone conduction and the air are equally elevated. 

To conduct the test, the patient will be placed in a sitting position to the audiometer located in a soundproof room.  There will be an audio copy examination which will be conducted as a way of ensuring that the external ear canal is not distracted.  The physician will then place earphones on the head of the patient over the ear canals.  A trial of the tone of 15-20 decibels above the required threshold will be delivered into the patient's ear for a second to ensure the patient is familiar with the sound as the test begins. During this time the client will also be advised to push a button each time she hears the tone.  The test results will then be plotted on the audiogram graph with the help of symbols which show the ear tested and responses with earphones (air condition) or oscillator (bone conduction) (Dobie, 2018).  For one to be in a better position of testing the air conduction, the client will be required to begin listening at 1000Hz and continue to decrease the intensity to 10db each time until the client is not able to hear a tone that means she will not press the button (Ertuğrul & Söylemez, 2019).  The physician will then increase the intensity to 5db at a time until the patient can hear the tone again. It is important to repeat these steps to the point that the same response is achieved 2/3 times at a similar level. 

Tone averages between: 

25-40 dB – for mild hearing loss

40-55 dB – for moderate loss

56-90 dB- for moderately severe to a severe loss

>90 dB - for a profound or total loss

Bone conduction- this is tested with the use of an oscillator that is going to be placed on a mastoid process behind the ear after the use of earphones (Ertuğrul & Söylemez, 2019). 

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Diagnostic results:

Hearing loss tuning fork tests – this will entail the use of a tuning fork of 1024 Hz which will be set to a light vibration with a  tap on the handle that is often used in differentiating the conduction hearing loss from the sensorineural hearing loss (Butskiy & Nunez, 2018 ). 

Weber test - This is about evaluating the bone conduction deafness. It entails tapping the tuning fork on the handle as a way of beginning the light vibration. In the process, one holds the base of the vibrating tuning form and puts it in the middle of their forehead (Ertuğrul & Söylemez, 2019).   During this test, it is important to ask the patient if she hearing the sound better and longer on one side than the other. This can be listed as weber right or left, or weber negative in case the sound is balanced. 

Rinne Test – the test is used in comparing air and bone conduction of sound in both ears.  In conducting this test one will tap the tuning fork as the client is moving the ear that is not being tested.  The tuning fork will then be placed in contact with the mastoid process. At this, the patient should be asked to verbalize if she no longer hears the sound.  The same vibrating fork will then be placed in front of the ear canal without having to cover or touch the external part of the ear (Ertuğrul & Söylemez, 2019). The patient will then be asked which of the two is going to have a longer or louder tone.  The test can be repeated in the other ear while recording as Rinne positive if the air conduction will be heard longer or will be Rinne negative in the event the bone conduct is also heard longer. 

Differential Diagnoses

1. Noise-induced hearing loss- In comparison to presbycusis, the noise-induced hearing loss is often sensorineural, bilateral, and will especially impact the ability to hear increased frequencies.  This type of hearing loss often occurs commonly among people in regions that have chronic exposure to loud noises (>85db) with little or no ear protection. For this, the patient will often report that the symptoms continue to worsen in crowded or noisy environments and they will usually develop tinnitus.  In this case, the patient reported that she can hardly hear in a crowded place and that she has to turn up the volume of the television to hear, making the noise-induced hearing the most likely diagnosis (Dobie, 2018). She however has not developed tinnitus as there is no history of tobacco smoking which disqualifies presbycusis. 
2. Presbycusis - This is usually common among older patients above 50 years.  A history of gradual sensorineural hearing loss, especially of higher frequencies will be highly suggestive of this diagnosis (Colucci, 2018). The patient will have a normal physical examination, as was done in this focused note, where the patient reported that the symptoms are worse in a crowded or noisy environment. Another risk factor is smoking. 
3. Medication-induced hearing loss - This condition will lead to sensorineural hearing loss which is also typically bilateral and will impact on higher frequencies. Usually, this will also lead to vertigo or tinnitus. In the event, that patient would have been exposed to ototoxic substances like Cisplatin and aspirin which puts her at the risk of medical induced hearing loss (Steyger, 2017).  Based on the history of present illness it seems that she began experiencing hearing loss for quite some time, while she also reports being using baby aspirin, this does not make medically induced the most likely differential diagnosis. Also, aspirin-induced hearing loss is often reversible, thus the patient can be counseled to discontinue usage. 

P (plan) 

The patient must be introduced to ear protection and hearing aids during normal activities like watching concerts, television, or using a lawn mower. In case she notices any differences regarding her hearing she should come aging for the next appointment for an examination.  However, if no changes occur she will be required to only be coming for an annual hearing examination or if she needs to check on her hearing aids (Ertuğrul & Söylemez, 2019).  It is important for the patient to also buy a wax cleaning kit that can be used to remove the wax from both her ears as this could also be a cause for conductive hearing loss in higher frequencies. 

Reflection

In this focused note, it was important to assess her medical history before taking her to the hearing booth.  The otoscopic examination was done for which the patient was responsive to the physician's directions during the assessment. There was a live monitored voice which was used to test the sound recognition and various tones for hearing.  Bone conduction was also done and a diagnosis was made. Based on this exercise, diagnosis of hearing loss is one of the most sensitive, time-consuming, and complex examinations. The patient was also educated regarding medical induce hearing loss and discouraged from using aspirin.  This was helpful as it ensures that whatever infection aspirin would have likely cause in her hearing, was going to be reversed.  It was also important to educate the husband and Mary about communication skills so she could know how to express her concern whenever she was hard of hearing.  This was also important since elder people with hearing loss are often neglected since other members of the family may not understand the situation that they will be going through. Other hearing therapies were also suggested such as music therapy which would be used in recognizing voices and genres. 

References

Butskiy, O., & Nunez, D. A. (2018). Diagnostic accuracy of parallel vs perpendicular orientation of the tuning fork in the identification of conductive hearing loss. JAMA Otolaryngology-Head & Neck Surgery, 144(3), 275. https://doi.org/10.1001/jamaoto.2017.3004

Colucci, D. (2018). Central presbycusis counseling. The Hearing Journal, 71(4), 44. https://doi.org/10.1097/01.hj.0000532400.06053.01

Dobie, R. (2018). Noise-induced hearing loss. Oxford Medicine Online. https://doi.org/10.1093/med/9780198834281.003.0099

Ertuğrul, S., & Söylemez, E. (2019). Investigation of the effect of hearing aid on hearing disability in elderly people with presbycusis. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE. https://doi.org/10.25000/acem.494922

Steyger, P. S. (2017). Is auditory synaptopathy a result of drug-induced hearing loss? The Hearing Journal, 70(4), 8-9. https://doi.org/10.1097/01.hj.0000515651.19741.fe