Nursing

Week 4 Case 2: Hearing Loss Mary

CC: My wife seems to be having trouble hearing me when I talk. She is turning the TV up really 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” Please add her projected weight and a BMI

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.

Diagnostic Testing: Please describe at least three (3) methods to 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.

What will your treatment plan for this patient be?

What other recommendations will you make (i.e., screening)?

What referrals will you make?

Education: Name at least two things you will educate your patient about regarding their hearing.

Choose the ROS, PE, and DD and final diagnosis for this patient, and then write up your focused SOAP note.

ANSWER

Week 4 Case 2: Hearing Loss Mary

ROS

Ramipril is an ototoxic drug that is used in treating high blood pressure and makes it easier to pump blood around the body. The patient has also been exposed to other high blood pressure treatment medicines such as bumetanide and furosemide which treat high blood pressure but can lead to hearing loss. The damage of these medicines is due to the changes that occur in the balance of fluids as well s salts in the inner ear which can lead to swelling of tissues and problems linked to transmission of the nerve signals. The patient has taken antibiotics which also have a high chance of causing hearing loss permanently. Additionally, the patient has also taken aspirins that induce temporary hearing loss which is linked to large doses. In case the patient took high doses not advised by the physician they might have a high risk of hearing loss.

PE

The first test is the examination of any suppuration or wax, then carry ABR, Weber, and Rinne Tests that will effectively enable one to rule out sensorineural and conductive hearing loss (Michels, Duffy & Rogers, 2019). For instance, the ABR test is a test that is used to examine the brain’s response to sound. OAE will be effective in examine the inner ear response to sound.  SSI and Berra tests will be done to examine the presence of recruitment. The areas that will need to be checked include EAC, inner ear, `tragus, temporal bone, and middle ear.

Diagnostic Testing

The diagnostic hearing tests include the Rinne test where the AC will be compared with the BC using the tuning fork. Rinne test entails evaluating loss of hearing in one ear. This kind of test compares the perception of sound that has been transmitted through the air to those that have been transmitted through bone conduction. Another essential test is the Weber test which is a quick, useful and simple screening test that evaluates hearing loss. The test can be detected through sensorineural and unilateral conductive hearing loss. Both Rinne and Weber tests are used to examine hearing loss. They enable the doctor to determine if the patient has sensorineural or conductive hearing loss (Lin, 2011). This examination enables the doctor to come up with an effective treatment plan that will facilitate hearing changes.

Auditory brain stem response(ABR) is a test that is used to tell how the Brain pathways and the inner ear cochlea are functioning. The ABR test is painless and safe for the patients and offers healthcare providers information about probable hearing loss.

Differential Diagnosis

Acoustic neuroma is a benign tumor that occurs on the vestibular and auditory nerves that lead from the inner ear to the brain (Zahnert, 2011). Therefore, the pressure that occurs from the tumor may lead to imbalance and hearing loss. Another major differential diagnosis for hearing loss is Tinnitus. Tinnitus is usually a result of age-linked hearing loss or an ear injury or an issue with the circulatory system. Meniere’s disease is another differential diagnosis that can be associated with the patient. Ideally, this is an inner ear disease that normally affects one ear. This can lead to pressure in the ear, roaring noise, and hearing loss.

Treatment Plan

An effective treatment plan will include a comprehensive assessment of the expressed and observed needs of the patient. To begin with, it is important to gather the related hearing history of the patient and determine the onset cause and consequence of the hearing problem The treatment plan will include changing the medications that are responsible for ototoxicity, ensuring soft noise in the patient’s room, hearing aids and therapy. Physical examination with the doctor and general screening tests will be effective in determining the possible causes of hearing loss. After examination of the hearing problem, treatment will depend on the severity and causes of the problem.

Recommendations

Hearing loss has been common among old age due to degenerative changes. Hearing impairment has threatened interactions with others. Of great concern has been its effects on personal independence, medical care, and safety. The patient should avoid listening to very loud sounds to prevent further damage and check for any deterioration in hearing. It’s important to inform friends and family that you have some hearing loss to easily help in communicating with others despite the hearing loss.

Referrals

The patient needs to visit other specialty health professionals to change the prescribed medications.

Education

With regards to hearing loss, the patient needs to understand the cause of hearing loss, hearing loss management, and the rehabilitative demands of the client. These will be effective in enhancing the adjustment of hearing loss.

References

Lin, F. R. (2011). Hearing loss and cognition among older adults in the United States. Journals of Gerontology Series A: Biomedical Sciences and Medical Sciences, 66(10), 1131-1136.

Michels, T. C., Duffy, M. T., & Rogers, D. J. (2019). Hearing loss in adults: differential diagnosis and treatment. American family physician, 100(2), 98-108.

Walling, A., & Dickson, G. (2012). Hearing loss in older adults. American family physician, 85(12), 1150-1156.

Zahnert, T. (2011). The differential diagnosis of hearing loss. Deutsches ärzteblatt international, 108(25), 433.