HEENT Capstone
Tiffany Allen
Department of Graduate Nursing, The University of Texas at Arlington
College of Nursing and Health Innovation NURS 5220: Advanced Health Assessment
Courtney Stewart, MSN, APRN, CPNP-PC
February 6, 2021
, SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
KU, 85 year old female, good historian, What is your date of birth? Does your family
have any history
of hearing loss?
Do you have
family history of
diabetes,
hypertension, or
stroke?
Personal/Social
Hx:
Chief Complaint/RFE: Pt lives in
Difficulty hearing
retirement
community.
Hx Present Illness: (7 Variables but do not list as such) Married.
Onset was “about two months” ago, noticed by her husband who “says he has to repeat himself
too many times” when talking to the patient. Pt reports it is worse on her right side and things
sound “hollow”. States she can hear noises “but speech isn’t clear”. Pt has tried cotton swabs to
relieve the problem without success. The problem is worse “in the evening” “in the dining hall”
and she is having to “watch people’s lips when they talk” to compensate, but “no one has been
shouting” at her. Pt states she has “never had any trouble” before two months ago and no recent
air travel. Pt reports frustration regarding this issue.
CURRENT HEALTH
Medications: Do you take any medications? How much and how often do you take
medications? Have you taken any antibiotics for an infection in the past few months? Are you
Tiffany Allen
Department of Graduate Nursing, The University of Texas at Arlington
College of Nursing and Health Innovation NURS 5220: Advanced Health Assessment
Courtney Stewart, MSN, APRN, CPNP-PC
February 6, 2021
, SOAP Note Form
Family Hx:
S/ Identifying Information: (initials, age/DOB, gender, reliability)
KU, 85 year old female, good historian, What is your date of birth? Does your family
have any history
of hearing loss?
Do you have
family history of
diabetes,
hypertension, or
stroke?
Personal/Social
Hx:
Chief Complaint/RFE: Pt lives in
Difficulty hearing
retirement
community.
Hx Present Illness: (7 Variables but do not list as such) Married.
Onset was “about two months” ago, noticed by her husband who “says he has to repeat himself
too many times” when talking to the patient. Pt reports it is worse on her right side and things
sound “hollow”. States she can hear noises “but speech isn’t clear”. Pt has tried cotton swabs to
relieve the problem without success. The problem is worse “in the evening” “in the dining hall”
and she is having to “watch people’s lips when they talk” to compensate, but “no one has been
shouting” at her. Pt states she has “never had any trouble” before two months ago and no recent
air travel. Pt reports frustration regarding this issue.
CURRENT HEALTH
Medications: Do you take any medications? How much and how often do you take
medications? Have you taken any antibiotics for an infection in the past few months? Are you
