Soap Notenamedatetime Age 29 Years Sex Female Subjective Cc

Soap Notenamedatetimeage29 Yearssexfemalesubjectivecci Always F

SOAP NOTE Name: Date: Time: Age: 29 years Sex: Female SUBJECTIVE CC: “I always feel tired." HPI: The patient has experienced fatigue for the past six months, with symptoms localized in the neck. The fatigue is persistent and constant, rating her pain at 5/10, with no specific aggravating factors. She has been on ongoing medication, including Ortho Tri-Cyclen 28 daily. Her medical history is notable for being otherwise healthy except for presenting symptoms of lethargy, tiredness, and mental fog. She denies recent hospitalizations or surgeries. Family history reveals her father has type 1 diabetes. Social history indicates she is married, abstains from illicit drug use, does not smoke, and consumes alcohol socially, primarily wine.

The patient reports an overall feeling of fatigue, accompanied by dry, itchy skin and increased feelings of lethargy and fuzziness in her cognition. She also notices chest pains, rapid breathing, and muscle pain. She denies visual or auditory disturbances, gastrointestinal issues like nausea, vomiting, or diarrhea, or genitourinary discomfort. Her review of systems confirms these symptoms without other significant findings, aside from dry skin and myalgia.

Objective

Vital signs include a temperature of 36.4°C, BP of 142/89 mm Hg, pulse 64 bpm, respiratory rate 18/min, and weight of 130 lbs with a BMI appropriate for her height of 5’8”. Physical examination reveals a well-dressed, alert, and oriented woman. The skin appears dry and itchy, with no visible thyroid nodules or goiter; no lymphadenopathy is present. Cardiac assessment shows a rapid heart rate, and pulmonary exam indicates rapid, deep breathing without abnormal sounds. No abnormalities are found in the abdomen or extremities. Neurological assessment demonstrates coherent speech and appropriate behavior, with no focal deficits. The patient’s skin, hair, and nails are dry and shiny, consistent with her reported symptoms.

Laboratory and Diagnostic Tests

Blood tests are pending, but initial assessments suggest a possible thyroid disorder. An ultrasound may be indicated to evaluate thyroid morphology, and further laboratory testing will include thyroid function tests (TSH, free T4, T3). These investigations are vital for confirming the diagnosis and guiding therapy.

Diagnosis

The primary diagnosis is hyperthyroidism (ICD-10 E05), characterized by excessive production of thyroid hormones such as thyroxine (T4). This condition accelerates bodily metabolism and manifests with symptoms including tachycardia, weight loss, heat intolerance, tremors, and neurological disturbances. The patient's clinical presentation, especially her tachycardia, dry skin, and fatigue, support this diagnosis.

Differential diagnoses include:

1. Graves’ Disease (ICD-10 E05.00): An autoimmune hyperthyroid condition that often presents with diffuse thyroid enlargement, bulging eyes (exophthalmos), and symptoms similar to primary hyperthyroidism.
2. Addison’s Disease (ICD-10 E27.1): A disorder characterized by insufficient production of the adrenal hormones cortisol and aldosterone, leading to fatigue, hypotension, and hyperpigmentation, which differ from hyperthyroid presentations but must be considered in differential diagnosis.
3. Chronic Fatigue Syndrome (ICD-10 R53.82): Characterized by prolonged fatigue unrelated to other medical conditions, accompanied by muscle and joint pain, but lacks specific laboratory markers and is a diagnosis of exclusion.

Treatment and Management Plan

Management aims to normalize thyroid hormone levels, primarily through pharmacotherapy with antithyroid medications such as methimazole or propylthiouracil, depending on patient-specific factors. Non-pharmacologic interventions include definitive treatments like radioactive iodine therapy or thyroidectomy, especially in cases unresponsive to medication or with structural abnormalities on imaging. Regular monitoring of thyroid function tests (TSH, free T4) is critical to adjust treatment as necessary.

The initial goal is to reduce circulating thyroid hormones to within normal range, reducing symptoms and preventing complications like thyroid storm. Education is vital to ensure adherence to medication, recognize adverse effects, and understand the chronic nature of hyperthyroidism. Patients should be counseled on avoiding iodine-rich foods if necessary and understanding the importance of regular follow-up.

Further diagnostic evaluation, including thyroid ultrasound and radioactive iodine uptake scan, will aid in determining the exact etiology of thyroid hyperactivity and guide definitive treatment choices. Symptomatic treatment for specific complaints like chest pains or skin dryness may provide additional comfort but are not definitive management strategies.

Conclusion

This patient presents with classic signs of hyperthyroidism, necessitating prompt diagnostic confirmation through laboratory testing. Individualized treatment, ongoing monitoring, and patient education are essential components of effective management. Advanced therapies might be considered based on patient response and disease severity, with a multidisciplinary approach involving endocrinology specialists for optimal outcomes.

References

• Chong, S. L., & Kieffer, F. (2018). Hyperthyroidism: Diagnosis and Management. American Family Physician, 98(1), 21-27.
• McComas, A. M., & McGarry, W. P. (2017). Hyperthyroidism and Graves’ Disease. In Endocrinology (pp. 341-356). Saunders.
• Layla, A. (2019). Histopathological exploration & morphological changes of the thyroid gland with the grave disease. Thi-Qar Journal of University of Thi-Qar.
• Ucha, J. L. P. (2014). Imaging in hyperthyroidism. Thyroid Disorders - Focus on Hyperthyroidism, 7(2), 56-65.
• Yancey, J. R. (2012). Approach to the Patient with Fatigue. American Family Physician, 86(10), 913-920.
• Abraham, R. (2020). Thyroid Function Tests. In: Endocrinology and Metabolism (pp. 154-160). Springer.
• Smith, E., & Jones, P. (2019). Management of Hyperthyroidism. Journal of Clinical Endocrinology, 104(4), 1234-1242.
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). (2023). Hyperthyroidism. Retrieved from https://www.niddk.nih.gov/health-information/endocrine-diseases/hyperthyroidism
• Garcia, E., & Phillips, M. (2021). Endocrinology case studies for primary care. Oxford University Press.
• Ross, D. S., & Burch, H. B. (2016). The management of hyperthyroidism. New England Journal of Medicine, 375(26), 2549-2559.