Patient Information: Mary, Female, 88 years old, African American, Married
Subjective
Chief Complaint
Mary is reported to be having issues hearing when other people speak to her. She has to turn the TV up really loud to hear it and is annoyed with having to do this often. When she is in a group of people, she has issues distinguishing between speech and does not understand it because several people are speaking simultaneously. The patient reports having tinnitus and feels that people are “mumbling” when they speak to her, which is a sign of deteriorating hearing.
HPI
88-year-old AA female;
- Location: Ears;
- Onset: several months:
- Character: issues hearing, tinnitus, issues concentrating, struggles distinguishing words when other people speak to the patient;
- Associated signs and symptoms: confusion, irritation;
- Timing: the majority of the time and daily interactions:
- Exacerbating/relieving symptoms: turning up volume makes hearing better; when the sounds are of low or moderate levels, the issues of the patient experience hearing;
- Severity: 8/10 in terms of difficulty hearing.
- Current Medications: Ramipril for hypertension (HTN) management, baby aspirin for cardio protection, and a statin for hypercholesteremia.
- Allergies: the patient does not report having any allergies to pharmacological substances.
- PMHx: immunization according to the recommended CDC (2022) schedule (IIV4), (VAR), (RZV), (PCV20).
- Soc and Substance Hx: Mary is a retired older woman who lives with her husband. She sees her family occasionally, and her daily activities include cooking, reading, watching TV, and going on light walks with her husband. The patient’s support system is strong, and her family is concerned about the hearing issues that cause discomfort in daily life.
- Fam Hx: There is no information regarding Mary has a history of hypertension in her family, even though she developed the condition over time while patient’s relatives’ causes of death and whether they were due to health complications are unknown.
- Surgical Hx: There is no information on any surgeries done on the patient.
- Mental Hx: The patient does not have a history of mental health issues. As she began experiencing challenges associated with hearing, she became more irritable and anxious because of the trouble hearing what people were saying. Social interactions got more complicated as Mary had to spend more time figuring out the subjects of the conversation.
- Violence Hx: At this time, there are no immediate concerns about the patient’s safety when she is at home. However, passing a street in a busier location may be a problem as Mary may not hear cars getting near her.
- Reproductive Hx: The patient is in her menopause and thus cannot have children.
ROS
General: No weight loss, fever, chills, fatigue, or overall weakness;
HEENT
- Eyes: no loss of vision, no blurring, or double vision;
- Ears, Nose, and Throat: great degree of hearing loss, tingling and buzzing in the ears, tinnitus; no sneezing, nasal congestion, or a sore throat.
- Skin: No itching or rash on the skin.
- Cardiovascular: no pain in the chest, no discomfort in the area. Occasional heart palpitations due to agitation or caffeine use.
- Respiratory: No shortness of breath, no cough or sputum.
- Gastrointestinal: No nausea, diarrhoea, or vomiting; no pain in the abdomen or blood in the stool.
- Gastrourinary: No burning on urination. No menstrual periods due to menopause.
- Neurological: No headaches, occasional dizziness when standing up swiftly. No changes in the control of the bladder or bowel.
- Musculoskeletal: Occasional pain in the back and muscles (possibly due to age) and stiffness in the joints.
- Hematologic: No bleeding, bruising, or anemia.
- Lymphatics: No enlargement in the nodes.
- Psychiatric: No history of the patient’s depression or anxiety.
- Endocrinologic: No intolerance to heat or cold, no sweating, no polydipsia or polyuria.
- Reproductive: not pregnant and no recent pregnancy (menopause), no vaginal discharge; not sexually active.
- Allergies: reported food allergies to citrus.
Objective
Physical Exam
The patient is normal in appearance, alert, oriented, and cooperates during an examination. Pupils are round, equal in size of 4 mm, and reactive to light and accommodation. The nasal mucosa is normal, tongue and gums are normal. Neck is easily movable without resistance. Lungs are clear to auscultation and percussion bilaterally. Vitals: BP 120/88, 88 P02: 96% WT: 156 HT: 5’6″.
ROS: The patient does not report recent exposure to ototoxic drugs nor a history of injuries to the ear. In childhood, she could have prescribed aminoglycoside antibiotics to fight infections caused by Gram-negative pathogens, but there is no data on this (Germovsek et al., 2017). To manage the fluid overload condition of hypertension, Mary could have been prescribed loop diuretics in the past, there is no current information on this either (Huxel et al., 2022). The assessment should take into account that exposure to loud noises could have been possible although remained unreported by the patient.
Diagnostic results: Pure-tone testing (air conduction testing) is carried out with the patient being asked to put on headphones and listen to a series of “beep” sounds, indicating which sounds they can hear. Through directing the sounds through the outer and middle ear, the test shows sensitivity to sound at different frequencies. Through tests involving bone conduction, it is possible to determine whether the loss of hearing is conductive, sensorineural, or both. Using a bone vibrator headset, the healthcare provider will send targeted sounds to the inner year. If the patient hears better with bone conduction, they most likely have conductive hearing loss emerging from the middle or outer ear (Manning, 2022). Hearing loss is likely to be sensorineural if a patient hears sounds equally well with the standard earphones and the bone vibrator.
The auditory brainstem response (ABR) examines the patient’s inner ear and brain hearing pathways for any signs of damage, which is used for diagnosing sensorineural hearing loss. The ABR test is carried out by placing electrodes on the head and connecting them to a computer, which records brain wave activity and tracks its response to sound. In Mary’s case, both bone conduction and pure-tone testing could be implemented.
Assessment
Differential Diagnoses
Among the three differential diagnoses applicable to the patient, the primary (presumptive) diagnosis includes hearing deficit and tinnitus, which are closely associated and could be grouped into one diagnosis. Tinnitus involves hearing noise in one or both ears, which is not caused by external sounds, thus causing a hearing deficit and disruption in normal hearing (Kennedy-Malone et al., 2019). It is notable that even though tinnitus interferes with hearing, it does not result in complete hearing loss. Inner ear damage is among the leading causes of tinnitus, which is associated with the damage of the hair cells in the inner ear, which results in random electrical impulses being shot to the brain. Tinnitus development has been linked to the exposure of an individual to loud sounds, age-related hearing loss, as well as changes within ear bones (CDC, 2020). Besides, the condition can be caused by such complications as cardiovascular disease, allergies, anemia, and jaw disorders (NIH, 2022). It is necessary to pay attention to such aspects as a patient’s diet, stress, and certain medications, all of which can contribute to the development of tinnitus.
Age-related hearing loss (presbycusis) is second in the list of differential diagnoses because the patient is eighty-eight years old, and it is not uncommon when a person begins to age. According to Cleveland Clinic (2021), age-related hearing loss affects around one in three adults over 65 years and one in two adults over the age of 75. Age-related hearing loss is presented through such symptoms as difficulty identifying higher pitches, having to read lips when other people are speaking, turning up the volume on TV or radio, tinnitus, as well as trouble understanding speech in crowded or noisy places (Cleveland Clinic, 2021). While the causes of presbycusis can range from one person to another, elderly adults are more likely to develop the condition if they have diabetes, a history of hearing loss in the family, as well as hypertension. Based on the symptomology and
Acoustic neuroma (vestibular schwannoma) is a non-cancerous and usually slow-growing tumor developing on the main nerve leading from the inner ear to the brain (Lustig, 2020). Branches of the nerve directly impact the balance and hearing, with pressure from acoustic neuroma causing hearing loss, unsteadiness, as well as ringing in the ear (Mayo Clinic Staff, 2021). The condition can be linked to an issue with a gene chromosome 22, which produces a tumor suppressor protein controlling the Schwann cells that cover the nerves. Notably, there is no consensus on what causes the problem in the gene. However, there is evidence that the faulty gene can be inherited in neurofibromatosis type 2, which is a rare disorder.
Plan
Several types of testing should be put in place to diagnose tinnitus and hearing deficit, age-related hearing loss, or acoustic neuroma in the patient. Tinnitus and hearing deficit could be diagnosed by the doctor based on the symptoms alone. A referral to an otolaryngologist and/or audiologist is necessary for carrying out pure-tone testing and a bone conduction test. The results of the testing will reveal the degree of hearing loss as well as whether it is conductive, sensorineural, or both. At this time, for a patient who is eighty-eight years old, there is no cure, with the treatment relying on the use of hearing aids and other listening devices that will alleviate the burden of difficulties and improve life quality.
It is likely that the patient’s conditions cannot be treated medically, such as through surgery, which will entail using a hearing aid recommended by an audiologist. In the case of tinnitus, as well as age-related hearing loss, hearing aids can help restore auditory stimulation of the brain, thus helping a person not being as affected by tinnitus (Newsted et al., 2020). The aids will amplify background noises, further stimulating the brain, and it is possible to install an aid that has tinnitus masking features. Overall, hearing aids represent the most appropriate solution for managing Mary’s hearing issues and helping restore good quality of life.
As the patient is given the correct hearing aid device that suits her needs, the treatment plan will include education. Mary should be educated on how to use the hearing aids, how to clean them, how to identify a malfunction, as well as how to get accustomed to wearing them. Besides, the patient will be educated on the importance of a healthy lifestyle and the management of hypertension and other diagnoses that have been identified. The combination of hearing improvement treatment and adherence to positive life habits is crucial for enhanced lifestyle quality.
Reflection
Reflecting on Mary’s case, the issues in hearing are most likely to be associated with her older age rather than with exposure to loud noises or any ototoxic medication. Ototoxic substances are harmful to the hearing on a long-term basis (Lustig, 2022). It could have been impactful if the patient revealed something about her occupation when she was working. Long-term exposure to loud noises at factories, construction, and other facilities could have led to her deteriorating hearing. Both research literature and healthcare organization-linked sources identified the connection between the risks of hearing complications and hypertension, which the patient experiences and for which she takes medication. Besides using hearing aids or assistive listening devices to help the patient hear better, it is recommended for Mary to manage her hypertension successfully and have regular meetings with her healthcare provider to correct treatment according to vital factors. Therefore, alleviating the burden of the patient’s hearing difficulties is not only concerned with finding the right treatment but also with the need to maintain an overall healthy lifestyle conducive to well-being.
References
CDC. (2020).How loud noise cause hearing loss?Web.
CDC. (2022). Recommended adult immunization schedule for ages 19 years or older. Web.
Cleveland Clinic. (2021). Age-related hearing loss (presbycusis). Web.
Germovsek, E., Barker, C. I., & Sharland, M. (2017). What do I need to know about aminoglycoside antibiotics?. Archives of disease in childhood. Education and Practice Edition, 102(2), 89–93. Web.
Huxel, C., Raja, A., & Ollivierre-Lawrence, M. (2022). Loop diuretics. Web.
Kennedy-Malone, L., Martin-Plank, L., & Duffy, E. (2019). Head, neck, and face disorders. In Advanced practice nursing in the care of older adults (2nd ed., pp. 127–151). F. A. Davis.
Lustig, L. (2020). Acoustic neuroma. Web.
Lustig, L. (2022). Drug-induced ototoxicity. Web.
Manning, M. (2022). 3 different hearing loss tests, and what you can learn from each. Web.
Mayo Clinic Staff. (2021). Acoustic neuroma. Web.
Newsted, D., Rosen, E., Cooke, B., Beyea, M. M., Simpson, M., & Beyea, J. A. (2020). Approach to hearing loss. Canadian Family Physician Medecin de Famille Canadien, 66(11), 803–809.
NIH. (2022). Age-related hearing loss. Web.