SOAP Note Form (Other (Not Listed) Sample)

SOAP Note FormStudent nameInstitutionDepartmentCourseModuleLecturerSubmission date SOAP Note Form Subjective: The patient is an 85-year-old Mrs. Kathryn Unterreiner, who reported partial hearing loss on her right side. Her spouse instigated the appointment after he noticed she had been having difficulty hearing for a "few months." Sounds on the right are reportedly hollow, "like an international phone call," according to the patient. The woman says she tried cleaning her ear canals with a cotton swab, but her problems have not improved. Objective: When inspected, a glob of cerumen blocked the right ear canal. The Rinne test demonstrates that air conduction is just as fast as bone conduction on the right side, and the Weber test lateralizes sound to that side. Assessment: Cerumen impaction is the most common cause of right-sided hearing loss due to conduction. The patient likely made matters worse when they tried to remove the cerumen with a cotton swab. Intervention: After softening with mineral oil and hydrogen peroxide, bulb syringes removed cerumen. The doctor warned the patient against removing cerumen using cotton swabs or other methods. Repeated Weber and Rinne tests improved. If symptoms continued, he told the patient to consult an audiologist and return for hearing testing. Plan: Schedule follow-up hearing test in 2 weeks * Advise patient to consult an audiologist if symptoms persist * Educate the patient on proper ear care and safe methods of cerumen removal. Medical Diagnosis: Primary Diagnosis: Impacted Cerumen (H61.23) Pathophysiology: Also known as earwax blockage, impacted cerumen do occur the wax in the ear builds up and becomes hard hence blocking the ear canal (Michaudet & Malaty, 2018). This blockage causes partial impairment of hearing. * Pertinent positives: Occlusion of the ear canal, difficulty hearing, fullness sensation in the ear. * Pertinent negatives: No ear pain, discharge from the ear, or tinnitus. * Secondary Diagnosis: Conductive Hearing Loss (H90.2) Conductive hearing loss (H90.2) Pathophysiology Conductive hearing loss occurs when sounds cannot move between the outer and middle ears. Low-volume noises may be hard to hear (Lauer et al., 2019). Suppress louder noises. Earwax blockage and other circumstances cause this. Treatments range from medication to surgery. * Pertinent positives: Difficulty hearing, lateralization of sound on the Weber test, air conduction equal to bone conduction on the Rinne test. * Pertinent negatives: No tinnitus, no ear pain, no discharge from the ear. Differential Diagnosis Otitis externa (H60.23) Pathophysiology As the name implies, otitis externa refers to irritation of the outer ear canal caused by a bacterial infection (Pye, 2018). It is often followed by temporary hearing loss, just as Mrs. Kathryn reported. * Pertinent positives: Ear pain, ear discharge, itching in the ear. * Pertinent negatives: No difficulty hearing, no lateralization of sound on the Weber test, and no air conduction equal to bone conduction on the Rinne test. Presbycusis (H91.3) Pathophysiology: Presbycusis causes nerve cells that process sound to lose hearing as part of aging. Hair cell degeneration in the inner ear causes a reduction of high-pitched noise perception (Boero et al., 2020). * Pertinent positives: Difficulty hearing...