Ototoxicity Focused SOAP Note

Ototoxicity

The Assignment

Complete the Focused SOAP Note Template provided for the patient in the case study. Be sure to address the following:

Subjective: What was the patient’s subjective complaint? What details did the patient provide regarding their history of present illness and personal and medical history? Include a list of prescription and over-the-counter drugs the patient is currently taking. Compare this list to the American Geriatrics Society Beers Criteria®, and consider alternative drugs if appropriate.

Provide a review of systems.

Objective: What observations did you note from the physical assessment? What were the lab, imaging, or functional assessments results?

Assessment: Provide a minimum of three differential diagnoses. List them from top priority to least priority. Compare the diagnostic criteria for each, and explain what rules each differential in or out. Explain you critical thinking process that led you to the primary diagnosis you selected. Include pertinent positives and pertinent negatives for the specific patient case.

Plan: Provide a detailed treatment plan for the patient that addresses each diagnosis, as applicable. Include documentation of diagnostic studies that will be obtained, referrals to other health-care providers, therapeutic interventions, education, disposition of the patient, caregiver support, and any planned follow-up visits. Provide a discussion of health promotion and disease prevention for the patient, taking into consideration patient factors, past medical history (PMH), and other risk factors. Finally, include a reflection statement on the case that describes insights or lessons learned.

Provide at least three evidence-based peer-reviewed journal articles or evidenced-based guidelines, which relate to this case to support your diagnostics and differentials diagnoses. Be sure they are current (no more than 5 years old) and support the treatment plan in following current standards of care. Follow APA 7th edition formatting.

Solution

Focused SOAP Note Template

Initials– Mrs. M, Age- 88 years old, Sex- Female, Race- African-American

S (subjective)

CC (chief complaint): Mrs. M has been having a hearing problem

HPI: The patient has a hearing problem. Has been hearing like people are mumbling rather than talking in high tones of voice

• Location: Ears
• Onset: Recent past
• Character: buzzing
• Associated signs and symptoms: she feels like people are mumbling
• Timing: Most of the time
• Exacerbating/relieving factors: N/A
• Severity: 7/10 scale

Current Medications: Ramipril for hypertension, baby aspirin for cardioprotection, a statin for hypercholesterolemia

Allergies: No reported allergies

PMHx: The patient suffers from hypertension and high blood cholesterol. Her last tetanus shot was in February 2021.

Soc and Substance Hx: The patient is a retired high school teacher who lives with her husband. They have been married for 50 years. She enjoys socializing with friends and reading. Has no history of alcohol or drug abuse. Has a strong support system from her children, family, and circle of friends.

Fam Hx: The patient suffers from hypertension and hypercholesterolemia

Surgical Hx: No history of surgery

Mental Hx: The patient has no history of mental illness or suicidal ideations

Violence Hx: No history of self-harm or violence

Reproductive Hx: The patient is not sexually active

ROS:

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

HEENT:

Eyes: No visual loss, blurred vision, double vision, or yellow sclerae.

Ears, Nose, Throat has hearing loss, no sneezing, congestion, runny nose, or sore throat.

SKIN: No rash or itching.

CARDIOVASCULAR: No chest pain, chest pressure, or chest discomfort. No palpitations or edema.

RESPIRATORY: No shortness of breath, cough, or sputum.

GASTROINTESTINAL: No anorexia, nausea, vomiting, or diarrhea. No abdominal pain or blood.

GENITOURINARY: No burning on urination.

NEUROLOGICAL: No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: No muscle, back pain, joint pain, or stiffness.

HEMATOLOGIC: No anemia, bleeding, or bruising.

LYMPHATICS: No enlarged nodes. No history of splenectomy.

PSYCHIATRIC: No history of depression or anxiety.

ENDOCRINOLOGIC: No reports of sweating, cold, or heat intolerance. No polyuria or polydipsia.

REPRODUCTIVE: Not pregnant and no recent pregnancy. No reports of vaginal or penile discharge. Not sexually active.

ALLERGIES: No history of asthma, hives, eczema, or rhinitis.

O (objective)

Physical exam:

Vitals: 120/88 P: 88 PO2: 96% WT: 156 HT: 5’6″

HEENT: Hearing Loss,

Diagnostic results: Some of the diagnostic tests that should be done on the patient include tuning fork tests, free-field hearing tests, and audiometer tests. The tuning fork tests enable the doctor to know the location of the ear damage as well as the detection of hearing loss (Hogan & Tadi, 2021). The two tuning fork tests done are the weber’s and Rinne’s tests where the tuning fork is struck to determine whether the patient hears the loudest sound at the center, right, or left.

The audiometer tests enable one to listen to sounds at different tones. The audiometer tests, tests sounds based on their intensity as well as the speed of sound waves. The free-field hearing test is examiner-dependent and reveals whether there is hearing impairment or not as well as the degree of the impairment. The patient is required to repeat back words and phrases as they hear them back to the examiner.

A (assessment)

Based on the patient’s history she has been taking Ramipril for hypertension and statin for hypercholesterolemia. The medications have been indicated to increase the risk of ototoxicity.  Other drugs that could result in tinnitus are painkillers and anti-anxiety medications.

Hearing loss should be one of the reasons to conduct an ear examination of both the external and the internal ears.

Differential diagnoses:       

Drug-induced ototoxicity

Drug-induced ototoxicity is the primary diagnosis based on the patient’s medical history (Barbieri et al., 2019). It refers to temporary or permanent hearing or balance disorders after pharmacological treatment. The patient is on Ramipril for hypertension and statin which nursing literature has associated with ototoxicity.

Blood vessel disorders

Blood vessel disorders such as high blood pressure can result in the blood moving through the veins and arteries causing tinnitus. The patient has hypertension, which justifies the differential diagnosis.

Autoimmune disease of the inner ear

Autoimmune disease of the inner ear is a situation where the immune system mistakenly attacks the inner ear. The disease causes dizziness, ringing in the ears as well as hearing loss.

P (plan)

Due to the patient’s health profile and possible interactions with medications, it would be important to use a treatment plan that would have minimal side effects on her health. The most suitable management plan would be the use of a hearing aid that would aid in the magnifying of sounds for better reception (Ciorba et al., 2018).

Reflection

The patient was educated on the importance of follow-up. She has also informed the need to visit her physician with the goal of discussing the side effects of the medications that she has been put on to manage her conditions and their possible link to her hearing loss. The patient verbalizes having understood her condition and the need for follow-up for a possible change of medications to minimize the risk of ototoxicity.

I will make referrals to her physician for the review of her medications. I will educate her on the need for regular ear checkups and the need to have her hearing aid to minimize further damage to her inner ear.

 

References

Barbieri, M. A., Cicala, G., Cutroneo, P. M., Mocciaro, E., Sottosanti, L., Freni, F., … & Spina, E. (2019). Ototoxic adverse drug reactions: a disproportionality analysis using the italian spontaneous reporting database. Frontiers in pharmacology, 10, 1161.

Ciorba, A., Corazzi, V., Bianchini, C., Aimoni, C., Pelucchi, S., Skarżyński, P. H., & Hatzopoulos, S. (2018). Autoimmune inner ear disease (AIED): A diagnostic challenge. International journal of immunopathology and pharmacology, 32, 2058738418808680. https://doi.org/10.1177/2058738418808680

Hogan, C. J., & Tadi, P. (2021). Ear Examination. StatPearls [Internet].