Case Study:
Mr. Roberts, a 67-year-old man, was referred to your office for a hearing evaluation. He continues to work in a printing company, although he works only part time. He has worked at the printing company for the past 35 years. He complains that he cannot hear much of the dialogue on the television. He is accompanied by his wife, who states that her husband cannot hear her at home. He has no history of dizziness, tinnitus, or vertigo. He has had cerumen impactions removed from both ears in the past.
VS: BP 138/72 Pulse 80 Resp 20 Temp 97.8 02 Sat 97%
PMH/PSH: Insomnia, bunion surgery right foot 10 years ago, vertebroplasty for L4 compression fracture 5 years ago.
Allergies: Penicillin - causes rash
Medications:
- Melatonin 5mg po qHS
- Multivitamin 1 po daily
- Ibuprofen 200mg 2 - 3 tabs PRN back pain
Social History: Married for 40 years to current wife, lives in one-story single-family home. Ran the presses for printing company for over 30 years, retired 2 years ago. He and his wife have 3 children who live out of the area, they also have 5 grandchildren that they like to visit several times a year. Never smoked, has history of alcohol misuse, stopped drinking 25 years ago, active member of the local AA chapter.
ROS: Difficulty hearing high frequency sounds, can't distinguish conversations in public areas, gradual onset of symptoms. Some issues with back pain especially with prolonged standing. Need Assignment Help?
Need a SOAP Note for the above with at least two to three latest References