ASSESSING, DIAGNOSING, AND TREATING HEAD, NECK, AND FACE DISORDERS
Case Study:
CC: My wife seems to be having trouble hearing me when I talk. She is turning the TV up loud.
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” BMI:_____
ROS: Ask if Mary has had any exposure to ototoxic drugs or other optic 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.
Diagnostic Testing: Describe at least three (3) methods to screen/or test for hearing.
You determine that Mary has a hearing deficit and tinnitus. What differential diagnoses do you want to consider? Describe at least three (one will be the primary dx).
What will your treatment plan for this patient be? Be specific
What other recommendations will you make (i.e., screening)?
What referrals will you make?
What education and follow up will you order?
Education: Name at least two things you will educate your patient about regarding their hearing.
Complete the Focused SOAP Note Template provided for the patient in the case study.
