Hypothyroidism SOAP Note – Week 4 Solution
This article covers a sample Hypothyroidism SOAP Note.
Hypothyroidism SOAP Note
| Data Needed | Data for this patient | |
| Patient Initials | KS | |
| Identifying Data | 2/22/1959 | |
| Source and Reliability | Patient and reliable. | |
| Age | 63 | |
| Gender | Male | |
| Occupation | Retired air force housing specialist. | |
| Marital Status | Widowed | |
| Subjective | ||
| Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – it may be a brief summary of the reason the patient wanted to be seen for this visit | “I cannot stop gaining weight although I am active. I have had swelling in hand and feet, feeling cold, muscle cramps, and constipation in the past two months.” | |
| History of Present Illness: Allergies: medications, food, environmental or seasonalChildhood Illnesses: chicken pox, rheumatic fever, rubella, measles, and mumpsAdult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric Health Maintenance Immunization status: DPT, MMR, influenza, hepatitis, polio, Pneumovax, herpes zoster Dental exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results) | KS is a 63-year-old African American male. This is his first time coming for a clinical examination in one year. He reports having a reasonably healthy life until the last two months when he started gaining weight uncontrollably. He reports remaining active and practicing yoga in vain. He also reports having constipation and fatigue most of the days. “At first, I thought constipation and fatigue would end, but they don’t.” The client also reports that I eat well. I am worried about my health.” The patient reports experiencing aggravating joint pains, usually around the knees and elbows, usually at night, but also affecting his movement. He relieves the pain by taking acetaminophen1300 mg PO q8hr PRN. However, the pain keeps coming back over and over again. | |
| Past Medical History: Allergies: medications, food, environmental or seasonalChildhood Illnesses: Adult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric Health Maintenance Immunization status: DPT, MMR, influenza, hepatitis, polio, Pneumovax, herpes zoster Dental exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results) | No known medication, environmental or food allergies Reports chicken pox – resolved on its own. Hypertension – Diagnosed in 2017. Well-controlled with medication. Type 2 Diabetes – Diagnosed in 2017. Well-controlled with medication. Last hemoglobin A1c was 6.9% 3 months ago. No history of injuries, surgeries, or hospitalization. Last dental exam – Every six months. Received all immunizations Eye exam – 2 weeks ago. MRD1 6mm. Exophthalmometer reading, 24. Current medication: Hydrochlorothiazide – 20 mg PO QD hypertension. No previous testicular/rectal exam. Lisinopril – 40 mg PO QD hypertension. Metformin – 1000 mg PO BID for diabetes. | |
| Family History: Include the presence or absence of specific illnesses in the family such as hypertension, diabetes, or cancer | Parents deceased. Paternal and maternal grandparents deceased. Father died at age 80 from Covid-19 complications and had type 2 diabetes. Mother died at age 65 in a road accident. Mother had type 2 diabetes and hypertension. Has a living sister aged 45, diagnosed with hypothyroidism and hypertension. Paternal grandfather died aged 88 from old age. Paternal grandmother died aged 85 from a myocardial infarction. Maternal grandfather died aged 87 from diabetes complications. Maternal grandmother died, aged 65, from breast cancer. | |
| Personal and Social History: Educational levelPersonal interestsLifestyle: exercise and dietOlder Adults: ADLs and iADLs | Bachelor’s Degree Democratic politics Practices yoga. Healthy diet. None – Care for by the house help. | |
| Review of Systems: General EyesEars/Nose/Throat EndocrineCardiovascularRespiratoryGastrointestinal Genitourinary Hematology/Lymph IntegumentaryNeckNeurological MusculoskeletalPsychological | 15lbs weight gain. Reports fatigue and weakness. Denies fever. Reports eye pain. Wears reading glasses. Ears: No hearing loss or discharge. Nose: No epistaxis or nasal congestion. Throat: Dental exam six months ago. No throat pain. As per HPI and PMH. No chest discomfort or palpitations. No wheeze, cough, or sputum. No pain with breath. Report constipation, abdominal pain, and diarrhea. Urinary frequency and nocturia in the past three months, four times per night. No urination pain. No erection in the past year. No easy bruising or bleeding. No history of blood clots. Coarse, scale, and dry skin. Neck stiffness and pain. No swollen glands. No headaches or vertigo. Reports focal weakness and gait instability. As per HPI. Reports anxiety. No depression or suicide ideation. | |
| Objective | ||
| Vital Signs and Measurements Blood pressureTemperaturePulseRespirationsHeightWeightBMI includes normal, overweight, obese, morbidly obese | 116/100 mmHg 98.7F 79 bpm 15 breaths /min 5’7’’ 180 lbs. 28.2 kg/m2, overweight. | |
| Physical Examination GeneralEyesEars/Nose/Throat Neck Endocrine Cardiovascular Respiratory Gastrointestinal Genitourinary Hematology/Lymph IntegumentaryNeurological Musculoskeletal Psychological | Well-developed African American male of the stated age. Alert and oriented in all spheres. Vital signs as per the measurements. The Head is normocephalic. No scalp. Facial tenderness and pink conjunctivae. Present bilateral arcus senilis. Eyes: Eyelid appears retracted, pupils equal in size. Sharp disc margins. Present venous/arteriole nicking. No eye exudates or hemorrhages were seen. Ears: Hearing is grossly intact. Moderate cerumen. Intact tympanic membrane. No erythema. Nose: Minimal septal deviation. Throat: No lesions or exudates. Palpable thyroid. Midline trachea. Distention of the jugular venous present, 8.5cm. No meningismus. Strong carotid upstrokes. No bruits. Cold intolerance, polyuria, and polydipsia are observable. Intercostal space, 4.3cm laterally from the midclavicular line. Symmetric thoracic expansion, dullness of both assess and bases. Regular rhythm and rate. S1 and S2 are normal physiologically. S3 is present, S4 absent. There is no observable respiratory distress. Remarkable breath sounds. No, wheezes or stridor. No tactile fremitus or bronchophony. Abdomen is non distended. No tenderness. hyopactive bowel sounds. No palpable masses. No lesions in the genital area. No inguinal hernia. Moderately enlarged rectum, symmetric, no nodule, and nontender. Cervical or axillary lymph nodes absent. Palpable lymph nodes. Present inguinal nodes, small and mobile, about 4.5mm in size. Coarse, scaly, and dry skin. Focal weakness and gait instability. Joint pain. No hand or bilateral knee deformities. Normal figure curls and movement. Strong muscles. Reduced range of motion. Appears anxious and lethargic. | |
| Assessment and Plan: based on current literature/guidelines. This should be organized and succinct. | Assessment Based on subjective and objective data, including constipation, lid extraction, lethargy, weight gain, coarse, scaly, dry skin, cold intolerance, and palpable goiter, the patient is likely to suffer from hypothyroidism. Also known as Hashimoto, autoimmune thyroid disease is coded as E06.3. Autoimmune thyroid disease is characterized by cold sensitivity, constipation, skin dryness and roughness, weight gain, fatigue, sexual dysfunction, and lid extraction (Arcangelo et al., 2017). The patient presents all these symptoms. The condition is caused by increased thyroid-stimulating hormone (TSH), free thyroxine (FT4), and reduced circulating free triiodothyronine (FT3) (Calsolaro et al., 2019). As a result, the fibrosis increases, and thyroid function decreases. Diagnostic Tests TSH (Thyroid-stimulating hormone) Test – Obtain a blood sample using a needle from the arm into a test tube. Normal TSH values are from 0.4 to 4.0 mIU/ Treatment Plan Start a partial replacement Levothyroxine Therapy with 0.8 mcg/kg of L-T4 with gradual increment using serum thyrotropin Levothyroxine is a standard therapy for hypothyroidism and is effective in resolving hypothyroidism symptoms (Jonklaas et al., 2014). Levothyroxine therapy is easily administered, has favourable side effects, long-term benefits, it is easily absorbed in the intestine, and has a long half-life. 2. Cardiac – Perform complete blood count and metabolic panel. Obtain chest radiograph. Start diuresis – Use furosemide, 40 mg IV at 12 hrs interval. Monitor weight. Liquid intake/urine output. 3. Ophthalmology: Begin eye drops to prevent glaucoma. 4. Maintain insulin for diabetes control and acetaminophen joint pain. 5. Health maintenance: Cancer screening up to date. Discuss appropriate dieting. | |
| Differential diagnoses, including ICD – 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings; articulate a rationale for the most likely diagnosis and each differential diagnosis. In this discussion, include pertinent positives and negatives, which help rule out or rule in each diagnosis. | Hypothyroidism – Hypothyroidism is characterized by cold sensitivity, constipation, skin dryness and roughness, weight gain, fatigue, sexual dysfunction, and lid extraction as presented by the patient (Arcangelo et al., 2017). This is the primary diagnosis.Congestive Heart Failure (CHF), ICD-10 Code 150.22. The essential diagnostic features of congestive heart failure presented by the patient include jugular venous distention, weight gain, and a history of hypertension (Ball et al., 2021). However, the client does not present other significant CHF diagnostic features including peripheral edema, pitting edema, ascites, or hepatomegaly. Therefore, this diagnosis is refuted. Unspecified Kidney Failure, ICD-10 Code N19. Kidney failure is a condition in which both kidneys fails to function temporarily and sometime can be chronic. The essential features of kidney failure presented by the patient include fatigue, polyuria, and dry/itchy skill (Chen et al., 2019). However, the client does not present swollen necks or ankles, muscle spasms, or poor appetite from considering the subjective and objective data obtained. Therefore, this diagnosis is refuted.Most likely diagnosis: (if more than one diagnosis, number each in order of priority) Include: Pathophysiology of the problemExplanation of the diagnosisDiagnostic TestingLab testingRadiology testingCardiac or Neurologic testingEvaluations – Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health EvaluationsMedications and Treatments – pharmacological and non-pharmacological treatments. Should include at least two evidence-based referencesMotivational Interviewing | Hypothyroidism The probable etiology of the patient’s condition is autoimmune thyroid disease/disorder. Autoimmune disorders attack body tissues (Calsolaro et al., 2019). Lab testing – Obtain blood sample using a needle from the arm into a test tube. Normal TSH normal values are from 0.4 to 4.0 mIU/L. TSH values above the normal range justify the diagnosis. Ultrasound – I recommend thyroid ultrasound to observe nodules usually present among patients diagnosed with hypothyroidism. Refer to an endocrinologist – For monitoring and management of hypothyroidism. |
| References (APA 7th format) | Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (2016). Pharmacotherapeutics for Advanced Practice, 4th Edition, Wolters Kluwer Health. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences. Calsolaro, V., Niccolai, F., Pasqualetti, G., Tognini, S., Magno, S., Riccioni, T., … & Monzani, F. (2019). Hypothyroidism is the elderly: who should be treated and how?. Journal of the Endocrine Society, 3(1), 146-158. https://doi.org/10.1210/js.2018-00207 Mathew, P., & Rawla, P. (2022). Hyperthyroidism. StatPearls [Internet]. https://pubmed.ncbi.nlm.nih.gov/30725738/ |
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