Focused Thyroid Exam

Focused Thyroid Exam

Episodic/Focused SOAP Note Template

Patient Information:

CH, 32 years old

S.

CC (chief complaint): CH isa 32-ar-old patient that came to the clinic with complaints of feeling tire and hair falling off.

HPI: CH is a 32-year-old patient that came to the clinic with complaints of feeling tired and hair falling out. She reported gaining 30 pounds of body weight in the last year. She also noted a marked decrease in appetite. The review of systems revealed that she does not sleep well and feels cold all the time. She still enjoys her hobbies and does not believe that she is depressed. The patient noted that symptoms such as feeling cold worsen in situations when exposed to stress, infection, or intense physical activities.

Current Medications: The client is not currently using any medications.

Allergies: The client denied any known allergy.

PMHx: The client denied any history of hospital admission or surgery. She also reported that her immunization records were up-to-date.

Soc Hx: The patient is married. She lives with her spouse and their daughter. She does not use or abuses drugs. They have smoke detectors in their home. Her family is her support system. She works as an accountant.

Fam Hx: The client denied any history of chronic illnesses in her family.

ROS:

Example of Complete ROS:

GENERAL:  Reports 30 pounds weight gain over the last year, denies fever, and chills. Reports fatigue and cold intolerance.

HEENT:  Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching. Reports cold intolerance and hair falling out.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood. Reports decrease in appetite.

GENITOURINARY:  Denies burning on urination. Her last menstrual period was 20/12/2022.

NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Denies enlarged nodes. No history of splenectomy. Reports cold intolerance.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Reports cold intolerance. No polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

Endocrinologic and integumentary: The patient appears overweight for her age. There is evidence of unintentional hair loss. The skin is cold on touch. The patient does not have enlarged thyroid.

Diagnostic results: The patient should undergo diagnostic investigations that include thyroid function tests, mental status examination for depression, and complete blood count. Thyroid function tests will rule out causes such as hypothyroidism or hyperthyroidism. Complete blood count is essential to rule out abnormalities such as an infection.

A.

Differential Diagnoses

Hypothyroidism: The client’s primary diagnosis is hypothyroidism. Hypothyroidism is a thyroid disorder characterized by hyposecretion of thyroid hormones. Patients develop symptoms such as hypotension, cold intolerance, weight gain, fatigue, hair loss, and menstrual irregularities (Chiovato et al., 2019).CH has most of these symptoms, hence, possibly suffering from hypothyroidism.

Major depression: Major depression is the client’s secondary diagnosis. Major depression is a mental disorder characterized by severely depressed mood. Patients develop symptoms that include feelings of guilt, hopelessness, anhedonia, sleep and appetite changes, difficulty in concentrating, and suicidal thoughts, attempts, or plans (Kraus et al., 2019). Major depression is the least likely diagnosis since the patient does not have depressed mood and anhedonia.

Hyperthyroidism: The other secondary diagnosis is hyperthyroidism. Hyperthyroidism develops from hypersecretion of thyroid hormone. Patients report symptoms such as heat intolerance, hypertension, weight loss, and hypertension (LiVolsi & Baloch, 2018). Hyperthyroidism is the least likely diagnosis since the patient has symptoms that are opposite to it.

This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Advances in Therapy, 36(2), 47–58. https://doi.org/10.1007/s12325-019-01080-8

Kraus, C., Kadriu, B., Lanzenberger, R., Zarate Jr., C. A., & Kasper, S. (2019). Prognosis and improved outcomes in major depression: A review. Translational Psychiatry, 9(1), Article 1. https://doi.org/10.1038/s41398-019-0460-3

LiVolsi, V. A., & Baloch, Z. W. (2018). The Pathology of Hyperthyroidism. Frontiers in Endocrinology, 9. https://www.frontiersin.org/articles/10.3389/fendo.2018.00737

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