Nursing -Soap Note Assignment
Nursing -Soap Note Assignment
SOAP Note for Hypothyroidism
Primary Health of Acute Client/Families Across the Lifespan-Clinical Practicum
SOAP Note for Hypothyroidism
SUBJECTIVE
ID: Mrs. J B, Age: 50, Race: African American, Gender: Female, Date of Birth: January 15, 1972, Insurance: N/A, Marital Status: Married.
CHIEF COMPLAIN: “I am experiencing fatigue. I want to rest even without working for long. I have increased 7 pounds in 3 months which is causing worry. I experience muscle cramps, and sometimes I get constipation. Nowadays, I can’t tolerate cold weather.”
HISTORY OF THE ILLNESS: A 50 years old African American female patient came to the clinic complaining about fatigue after light tasks. The patient reports gaining weight fast, which is causing a lot of worries to her. The patient works in a restaurant not far away from where she lives. Her job is highly demanding, and she has to keep on walking. The patient disagrees with having seasonal allergies, shortness of breath, chest pains, or frequent headaches.
PAST MEDICAL HISTORY: None
CURRENT MEDICATIONS: None
IMMUNIZATION: The patient is up-to-date with her immunizations.
FAMILY HISTORY: The patient’s father passed away at age 72 and succumbed to throat cancer and memory loss. The patient’s mother died at 68 after suffering from hypertension and depression for three years. The patient has a brother who has a history of stomach ulcers, and he struggles with alcoholism. Her sister is healthy, and she has no known medical history. The patients’ paternal grandmother died at 89 of a stroke resulting from food poisoning. Her paternal grandfather also succumbed to stomach ulcers.
SOCIAL HISTORY: The patient lives with her husband and 1 of their four children. She worked at an airport before switching to a restaurant. The patient admits to being an alcoholic in her 20s but stopped in her early 30s. She claims not to have any experience with hard drugs. The patient is sexually active and only with her husband. She used to go to the gym to maintain her body weight, but the fatigue made her find difficulties exercising. She is a Christian and follows all Christian virtues. The patient enjoys cool music and playing with her last-born son. Nursing -Soap Note Assignment
REVIEW OF SYSTEMS
GENERAL: The patient reports weight gain and fatigue. She denies a high fever, nocturnal sweats, and a change in appetite.
HAIR, SKIN, AND NAILS: The patient denies rashes, no color changes, no sunburns, and nodes.
HEAD: The patient denies frequent headaches, visual changes, redness, no injury, or drainage.
NECK: The patient does not feel pain or stiffness in the neck—no noted masses or edema.
EYES: No scotomata, no tearing, no pain. The patient has normal vision.
EARS: The patient denies bleeding, having any hearing difficulties, bleeding, tinnitus. No vertigo.
NOSE: Denies nasal obstruction, drainage, or redness
MOUTH & THROAT: The patient denies edema, sore throat, complications absorption, hoarseness, no dental complications, no use of dentures.
CARDIOVASCULAR: The patient doesn’t suffer from peripheral edema, chest pain, or palpitations.
GASTROINTESTINAL: The patient disagrees with having abdominal pain. She disagrees with having nausea, disgorging, or cramps.
PULMONARY: Normal
ENDOCRINE: The patient has a normal appetite and denies extreme thirst or unconscious prejudice.
LYMPHATICS: The patient has negative tender lymph nodes.
GENITOURINARY: there is an absence of dysuria
MUSCULOSKELETAL: The patient refutes redness and edema to muscles.
NEUROLOGICAL: There are no cognitive or disorientation problems with this patien
PSYCHIATRIC: The patient denies extreme sadness, mood fluctuations, or sleeplessness.
ALLERGIC: no known allergies.
OBJECTIVE
VITAL SIGNS: Temp- 98.9, Pulse- 77, Resp-22, O2- 98% RA, BP- 141/81, weight- 146 lbs., height- 6’.9”, BMI-25.0
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PHYSICAL EXAMINATION
GENERAL APPEARANCE: Vigilant, well combed. No acute pains were detected. She is presentable.
HEENT: Normocephalic. Atraumatic. Eyes: PERRLA. No nystagmus bilateral, Pupils are equal, round, and sensitive to light reconciliation. Ears: Bilateral outer ears are normal, free from drainage. Nose: Sputum is midline. No alterations. It is symmetrical, and vessels expound in the mutual snout with transparent drainage.
NECK: Flexible and balanced. No tracheal variation. No goiter noted—no inflamed lymph lumps.
ABDOMEN: The patient has a gentle and non-tender flat belly. There was no inguinal found. No ascites were discovered.
RESPIRATORY: Normal.
CARDIOVASCULAR: regular S1 & S2, heart rate is standard, no murmurs in a heartbeat.
GENITOURINARY: No wing, suprapubic sympathy, or CVA devotion.
SKIN: Skin is mild and dry. The legs appear dry and darker.
MUSCULOSKELETAL: No joint malformation was noticed. Her spine aroused straight calibration without any curving.
NEUROLOGIC: No cerebellar signs or symptoms, no neural shortfall.
PSYCHIATRIC: Factual to time. Content and appropriate. Nursing -Soap Note Assignment
ASSESSMENT
DIFFERENTIAL DIAGNOSIS
HYPOTHYROIDISM: ICD-10-CM- E03.9
Hypothyroidism is a disease that is caused by fewer thyroid hormones being generated by the Thyroid. Fewer thyroid hormones in the bloodstream can cause slow metabolism. The condition is known as an underactive thyroid. It makes the victim feel exhausted and also increases weight fast. They can also not withstand cold weather (Bekkering et al., 2019). Some of the signs associated with this disease include; fatigue, weight gain, slow heart rate, high sensitivity to cold, and a puffy face.
GOITER: ICD-10-CM-E04.9
This disease occurs when the thyroid gland inflates than usual. The thyroid gland below Adam’s apple becomes huge, causing stiffness in the neck. Lack of iodine in the diet may lead to this disease (Doulaptsi et al., 2019). More signs include swelling neck vein and swelling in the front part of the neck. The symptoms presented did not match this disease, which was disqualified.
THYROID CANCER ICD-10-CM-C73
Thyroid cancer is a type of cancer that affects the thyroid gland’s malignant cells and tissues. Breathing problems, enlargement in the neck, and tenderness in the front region of the neck are some of the disease’s signs and symptoms.The risk factors include a family history of goiter, particular congenital ailments, and radiation exposures (Filetti et al., 2019). The diagnosis was dropped since the patient did not have signs and symptoms attributed to the disease.
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PLAN
FINAL DIAGNOSIS: HYPOTHYROIDISM
The patient is most certainly suffering from hypothyriodism, as his symptoms closely matched the signs and symptoms of the disorder. Hypothyriodism will also be confirmed with lab tests, which will show a high TSH level.
DIAGNOSTIC LAB TEST
-Thyroid test- a thyroid test was done to indicate thyroxines and the levels of thyroid-stimulating hormones.
-When there is a high TSH level test, the test should repeaed and a free T4 should be added
-Thyriod scan
-CBC for aneamia
-Lipid profile
-.Nodules are detected by ultrasound of the neck and thyroid. This is not the basic test.
DIAGNOSIS:
TREATMENT: Prescription: levothyroxine 25 mcg per day. For eight weeks
The medication is effective in restoring the levels of the hormone. It helps reverse hypothyroidism signs and symptoms.
EDUCATION:
Patients should be educated on the nature and evolution of the disease, as well as the signs and symptoms. Teach the patient to report any tachycardia, palpitation, or chest pain as a side effect of levothyrioxine or desiccated thyroid medication. The importance of lifelong levothyroxine medication and the risks of noncompliance were emphasized to the patient. The patient was advised to eat food rich in iodine. Food rich in iodine is essential for the restoration of thyroid hormones. She was advised to avoid the cold by wearing protective clothing. She was also advised to drink water within the recommended constraints. She was advised to consume food with high fiber. The absorption of levothyroxine is reduced when you drink coffee. Exercises are important to reduce weight. She was advised to keep on practicing to reduce her weight. Nursing -Soap Note Assignment
FOLLOW-UP: The patient should come back after 4 to 6 weeks to monitor lab values and patient well-being.
References
Bekkering, G. E., Agoritsas, T., Lytvyn, L., Heen, A. F., Feller, M., Moutzouri, E., … & Vermandere, M. (2019). Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. Bmj, 365.
Doulaptsi, M., Karatzanis, A., Prokopakis, E., Velegrakis, S., Loutsidi, A., Trachalaki, A., & Velegrakis, G. (2019). Substernal goiter: Treatment and challenges. Twenty-two years of experience in diagnosis and management of substernal goiters. Auris Nasus Larynx, 46(2), 246-251.
Filetti, S., Durante, C., Hartl, D., Leboulleux, S., Locati, L. D., Newbold, K., … & Berruti, A. (2019). Thyroid cancer: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Annals of Oncology, 30(12), 1856-1883.
