HEENT Capstone
Amber Carter
Department of Graduate Nursing, University of Texas at
Arlington College of Nursing and Health Innovation
SOAP Note
Form
Family Hx:
Ask patient
about family
hx as it
pertains to
current
S/ Identifying Information: (initials, age/DOB, gender, problem.
reliability) History of
family hearing
loss.
K.U
85-year-old Female Personal/Social
Hx:
Chief Complaint/RFE: Married
Hard of hearing
Resides in a
retirement
Hx Present Illness: (7 Variables but do not list as such) community
Pt presents with decreased hearing on the right side that began about 2 months
ago. The visit was prompted by the patient’s husband observation regarding her
trouble hearing. Patient states that everything sounds funny and can hear noises
but speech isn’t clear and states that it is worst in her right ear. Patient states
she has the most trouble In the dining hall in the evening. Patient states that her
husband and best friend have been having to repeat themselves when talking to
her lately. Patient reports sounds on the right are hollow. The patient reports
that she attempted to treat the problem by using a cotton swab “in case there
was some wax in there”, the patient reports that nothing came out on the swab
and it did not resolve the problem. The patient says that she watches people’s
lips when they talk in noisy
[Date]
1
,restaurants or sometimes just does not listen and that it is frustrating.
CURRENT HEALTH
Medications: Ask patient of current medications taking at home.
Allergies: Ask patients about allergies
Last PE & Screenings: Ask patient of last physical and screening and if she gets
regular
screenings and check-ups
Immunization Status: Ask patient if she is up to date on all immunizations?
Pneumovax? Flu?
Shingles?
LMP & Birth Control (if applicable) : Patient is 85 and menopausal
PMH
Illnesses & Trauma: Ask patient of any recent illnesses, falls?
Hospitalizations/Surgeries: Ask patient if she has been hospitalized recently. Ask
patient
about past surgical history.
OB Hx/Sexual Hx: Ask patient about current sexual practices
Emotional/Psy Hx: admits to having frustration with current situation of not
being able to
hear
REVIEW OF SYSTEMS
General: document and assess if patient appears clear, in good hygiene, note how
the patient
[Date]
2
, is dressed, if they look disheveled or not.
Nutrition: inspect if the patient appears to be well nourished or malnourished.
Skin/Hair/Nails: Inspect hair and document, inspect nails and look for clubbing,
brittleness,
deep ridges or cyanosis
HEENT: Patient reports hearing loss worse in right ear, reports sounds are
“hollow”, inspect skin for bruising or discoloration and look for tenting. Ask
patient about glasses or contact use. Ask the patient if vision is blurry, or if they
have any tearing, itching, or acute vision loss. Ask patient if they have tinnitus,
discharge or earache. Ask patient about rhinorrhea, stuffiness, sneezing, itching,
epistaxis, or allergies. Ask patient about bleeding gun,
hoarseness, sore throat or swollen neck.
Breasts: n/a
Respiratory: ask patient about shortness of breath, wheezing, coughing, sputum,
hemoptysis,
asthma, pneumonia, bronchitis, emphysema, or if they have ever had/been
treated for TB
CV/peripheral vascular: Ask patient about HTN, murmurs, palpitations, dyspnea
on exertion,
orthopnea, or edema.
GI: Discuss and as patient about any changes in appetite, weight gain or weight
loss, ask patient about nausea and vomiting, or difficulty swallowing. Ask
patient if they have had any
diarrhea or constipation, bleeding, hemorrhoids or abdominal pain.
GU: Ask patient if she has incontinence, painful urination, polyuria, or nocturia.
MSK: Ask patient if she has any muscle weakness, pain or joint stiffness,
decreased ROM, or
redness and swelling in joints.
Psych: Patient reports feeling frustrated at times when she is unable to hear or
read
someone’s lips. Ask patient about anxiety, depression, or memory problems
Neuro: Ask patient about numbness/tingling, tremors, weakness, fainting, or
history of
seizures.
Lymph/Heme/Endocrine: Ask patient about history with anemia, easily
bruising/bleeding, petechiae, previous blood transfusions, history of thyroid
issues, fatigue, weight gain or
weight loss, heat/cold intolerance, polyuria, polydipsia, polyphagia
O/ Physical Exam: T: P: R: BP: HT: WT: BMI: ** I would
record all these vitals at time of
visit**
General: record that patient is female if she appears to be in good health,
nourished vs.
malnourished, and functionality
Skin: Perform assessment and include the temperature of the patient’s skin, if
skin is intact, if
any bruising is present or wounds, if patients’ skin is dry or clammy
Head: assessment of the head to include shape of head, and record any trauma or
[Date]
3
Amber Carter
Department of Graduate Nursing, University of Texas at
Arlington College of Nursing and Health Innovation
SOAP Note
Form
Family Hx:
Ask patient
about family
hx as it
pertains to
current
S/ Identifying Information: (initials, age/DOB, gender, problem.
reliability) History of
family hearing
loss.
K.U
85-year-old Female Personal/Social
Hx:
Chief Complaint/RFE: Married
Hard of hearing
Resides in a
retirement
Hx Present Illness: (7 Variables but do not list as such) community
Pt presents with decreased hearing on the right side that began about 2 months
ago. The visit was prompted by the patient’s husband observation regarding her
trouble hearing. Patient states that everything sounds funny and can hear noises
but speech isn’t clear and states that it is worst in her right ear. Patient states
she has the most trouble In the dining hall in the evening. Patient states that her
husband and best friend have been having to repeat themselves when talking to
her lately. Patient reports sounds on the right are hollow. The patient reports
that she attempted to treat the problem by using a cotton swab “in case there
was some wax in there”, the patient reports that nothing came out on the swab
and it did not resolve the problem. The patient says that she watches people’s
lips when they talk in noisy
[Date]
1
,restaurants or sometimes just does not listen and that it is frustrating.
CURRENT HEALTH
Medications: Ask patient of current medications taking at home.
Allergies: Ask patients about allergies
Last PE & Screenings: Ask patient of last physical and screening and if she gets
regular
screenings and check-ups
Immunization Status: Ask patient if she is up to date on all immunizations?
Pneumovax? Flu?
Shingles?
LMP & Birth Control (if applicable) : Patient is 85 and menopausal
PMH
Illnesses & Trauma: Ask patient of any recent illnesses, falls?
Hospitalizations/Surgeries: Ask patient if she has been hospitalized recently. Ask
patient
about past surgical history.
OB Hx/Sexual Hx: Ask patient about current sexual practices
Emotional/Psy Hx: admits to having frustration with current situation of not
being able to
hear
REVIEW OF SYSTEMS
General: document and assess if patient appears clear, in good hygiene, note how
the patient
[Date]
2
, is dressed, if they look disheveled or not.
Nutrition: inspect if the patient appears to be well nourished or malnourished.
Skin/Hair/Nails: Inspect hair and document, inspect nails and look for clubbing,
brittleness,
deep ridges or cyanosis
HEENT: Patient reports hearing loss worse in right ear, reports sounds are
“hollow”, inspect skin for bruising or discoloration and look for tenting. Ask
patient about glasses or contact use. Ask the patient if vision is blurry, or if they
have any tearing, itching, or acute vision loss. Ask patient if they have tinnitus,
discharge or earache. Ask patient about rhinorrhea, stuffiness, sneezing, itching,
epistaxis, or allergies. Ask patient about bleeding gun,
hoarseness, sore throat or swollen neck.
Breasts: n/a
Respiratory: ask patient about shortness of breath, wheezing, coughing, sputum,
hemoptysis,
asthma, pneumonia, bronchitis, emphysema, or if they have ever had/been
treated for TB
CV/peripheral vascular: Ask patient about HTN, murmurs, palpitations, dyspnea
on exertion,
orthopnea, or edema.
GI: Discuss and as patient about any changes in appetite, weight gain or weight
loss, ask patient about nausea and vomiting, or difficulty swallowing. Ask
patient if they have had any
diarrhea or constipation, bleeding, hemorrhoids or abdominal pain.
GU: Ask patient if she has incontinence, painful urination, polyuria, or nocturia.
MSK: Ask patient if she has any muscle weakness, pain or joint stiffness,
decreased ROM, or
redness and swelling in joints.
Psych: Patient reports feeling frustrated at times when she is unable to hear or
read
someone’s lips. Ask patient about anxiety, depression, or memory problems
Neuro: Ask patient about numbness/tingling, tremors, weakness, fainting, or
history of
seizures.
Lymph/Heme/Endocrine: Ask patient about history with anemia, easily
bruising/bleeding, petechiae, previous blood transfusions, history of thyroid
issues, fatigue, weight gain or
weight loss, heat/cold intolerance, polyuria, polydipsia, polyphagia
O/ Physical Exam: T: P: R: BP: HT: WT: BMI: ** I would
record all these vitals at time of
visit**
General: record that patient is female if she appears to be in good health,
nourished vs.
malnourished, and functionality
Skin: Perform assessment and include the temperature of the patient’s skin, if
skin is intact, if
any bruising is present or wounds, if patients’ skin is dry or clammy
Head: assessment of the head to include shape of head, and record any trauma or
[Date]
3
