Graves Soap Note Example PDF

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Althea Titus-Grant Soap Note # 1 CHIEF COMPLAINT (CC): “I am here because I am having palpitation and anxiety; had abnormal thyroid scan and lab results that was ordered by my PCP.” HISTORY OF PRESENT ILLNESS (HPI): KB is a 49 year old Caucasian female who presented to the practice with a complaint of tachycardia, anxiety, hyperactivity and insomnia. She informs that she has been having difficulty sleeping at nights for about 3 months, and has gotten worse within the last 3 weeks. She informs that even though she is unable to sleep at nights, she does not feel tired during the day and just want to keep moving. She states that she is very anxious and irritable, especially with her husband for no apparent reason. Complains of palpitations. She also informs that her heart beats so fast it feels like is jumping out of her chest. She explains that her symptoms has exacerbated within the last week and that she has been having dry mouth, diarrhea and weight loss. At this point she visited her PCP who ordered the laboratory tests. The diarrhea started 2 days ago, and she has been having 3 to 4 loose stools each day. She stated that she is constantly hungry even though she eats a large meal at breakfast, lunch and dinner. She explains that he has been experiencing dizziness, but no falls. Patient denies any recent viral illnesses. PAST MEDICAL HISTORY (PMH): Childhood Illness: Denies childhood illness Adult Illnesses: Denies adult illnesses. Surgical: Denies surgical procedures. OB/GYN: Nulligravida and nullipara. Psychiatric: Patient denies any psychosis, mood disorders, depression, mania, or post-traumatic stress disorder (PTSD), premenstrual stress disorder (PMSD). Accidents or Injuries: Denies past accident, trauma, falls or injuries Hospitalizations: Denies past hospitalization Operations: Denies past operations or surgeries

HEALTH CARE MAINTENANCE: Last Pap Smear: 11/2013 Mammogram: 11/2013 Self-Breast Examination (SBE): Patient denies doing self –breast examination. Dental Examination/Cleaning: 11/2013

Last Eye Examination:

11/2013

Hearing Examination: Remote history. Lipid Screening: Denies lipid screening. Diabetes Screening: Denies diabetes screening.

CURRENT MEDICATIONS: Denies current prescription medication use; except for IUD. Takes daily OTC MVM.

IMMUNIZATIONS: Influenza: 10/2013 Pneumococcal: Denies receiving the pneumonia vaccine. Tetanus/Pertussis: tdap 3 years ago.

ALLERGIES: Drug: NKDA Food: Denies food allergies. Environmental: Denies environmental allergies. Seasonal: Denies seasonal allergies.

SOCIAL HISTORY: Smoking: Patient denies Drug Use: Patient denies Alcohol: Patient denies daily use; drinks 1-2 glasses wine occasionally. Sexually Health: Patient states he is married and has a monogamous relation with her husband of 7 years. Spiritual and Cultural Beliefs: Patient states he is of Christian belief and attends a nondenominational church. Safety: Admits to wearing seat belt. Living Situation/Working Situation: Denies exposure to radiation, smoke, chemicals fumes, loud noise.

Occupation: Clerical Assistant to a local marketing company. FAMILY HISTORY: Mother: Alive, age 76. Diabetes Mellitus Type 2, HTN. Father: Alive 74 years old. Has arthritis and IBS. Brother(s): Alive and well, age 45. Sister(s): None. REVIEW OF SYSTEMS GENERAL: Patient admits weight loss, and fatigue. Denies fever and chills. EYES: Patient admits to blurry vision, dry eyes and bulging eyes, irritation and drainage. EARS: Patient denies earache, drainage, tinnitus, loss of hearing. NOSE: Patient denies congestion, nosebleed, sinus tenderness, or post-nasal drainage. THROAT & NECK: Patient admits to diffuse gaiter, hyperorexia, polydipsia, and hoarseness; denies dysphagia, or sore throat. CARDIOVASCULAR/PERIPHERAL VASCULAR: Patient denies orthopnea, paroxysmal nocturnal dyspnea (PND, chest pain and ankle edema; admits to occasional SOB, tachycardia, and dizziness. PULMONARY: Patient denies cough, sputum production, and dyspnea on exertion, hemoptysis, or wheezing. Admits to shortness of breath. GI: Patient denies nausea, vomiting, constipation, melena, hematochezia, reflux, indigestion, dysphagia, or hemorrhoids, and recent abdominal trauma. Admits to diarrhea that started 2 days ago; 3-4 loose stools daily. Admits to polyphagia and weight loss that started about 3 months ago. GU: Patient denies to hematuria, polyuria, vaginal discharge, bilateral costovertebral angle (CVA) tenderness, or bilateral flank pain. Denies urinary urgency or foul-smelling urine, denies pelvic pain. REPRODUCTION: Admits menstrual irregularities, and infertility NEURO: Denies headache, paresthesia, paralysis, numbness, tingling, and loss of sensation, seizure, or syncope. Admits to tremors and hyperreflexia. MUSCULOSKELETAL: Admits to proximal myasthenia, arthralgia and myalgia. DERMO: Admits to hair loss, pruritus, hyperhidrosis; warm moist palms. Denies brittle nails. HEME: Denies easy bruising or swelling of lymph nodes, easy bleeding of the skin or mucous membranes, or blood transfusions.

ENDO: Denies intolerance to cold. Admits to heat intolerance polydipsia, polyphagia, excessive sweating. Admits to skin constantly feeling hot even after a cool shower. PSYCH: Denies suicidal ideation, depression, hallucinations, and paranoia. Admits to anxiety and nervousness.

PHYSICAL EXAMINATION APPEARANCE: Alert, well groomed, unable to focus and fully engage in conversation; answers are supplemented by spouse; patient in obvious distress. Vital signs: Pulse 115, Temperature 99.5 F Respiration 22, BP 148/54, Pulse Ox 99% RA, Height 5’5”, Weight 127 lbs, BMI 19.5. HEAD: Normpcephalic, atraumatic, erect and centered at top of cervical spine, no abnormal facial movements, hair is unevenly distributed, with same fine texture and quantity. No scales, redness, open lesions, scabbed areas, no swelling or masses. No facial involuntary movements or tics, facial skin smooth and velvety; warm, unbroken and clean. Temporomandibular joint (TMJ) smooth with movement. Frontal and maxillary sinuses nontender when palpated. Thyroid is enlarged with 2 palpable nodules of the right and 1 on the left. Lymphnodes nonpalpable, and non-tender. Cortaid pulse regular, full and smooth. No jugular vein distention (JVD) noted. EYES: PERRLA, EOMI, Conjunctiva, anicteric. Scant amount of tearing, no sores, or lesions, lateral canthus is aligned to pinnacle of ears, eyebrows and eyelashes are symmetrical and hair is evenly distributed, eyelids closes completely, overt periorbital edema with proptosis. EARS: Ears are symmetrical, external auditory canal patent and free of nodules, cysts, drainage, inflammation or obstruction; cerumen present but not excessive or impacted. Tympanic membrane intact, shiny, translucent, and pearly grey. Bilaterally positive cone of light, bony landmark visible, no fluids, hearing intact and patient responds appropriately to questions. NOSE: Nose is midline, no visible deformities, no nasal flaring, no external lesions or injury. Nasal septum is midline; pink and moist. MOUTH: Lips are smooth and dry, no cracks, lesions, or sores, tongue is pink and moist; without sores, or lesions, good dentition; no missing teeth, no bleeding of gum, uvula midline, no exudate or foul odor. THROAT: Hoarseness is noted, no difficulty swallowing. Tongue is midline, pink and moist and slightly rough, floor of mouth is void of red or white spots. NECK: Trachea midline at patient’s neck. Thyroid is enlarged; smooth diffused goiter with 2 palpable nodules of the right and 1 on the left. SKIN: Intact, no moles, sores, lesions, or discoloration of visible areas. Skin is smooth, velvety. Warm, moist palms. Hair was sticking to her neck from perspiration.

CV: Rapid S1 and S2 heart sounds; no murmur. No JVD, or peripheral edema to bilateral lower extremities. Skin turgor with sluggish recoil at supraclavicular line, no carotid bruit auscultated. PULMO: Lungs are clear to auscultation, labored breathing and evidence of respiratory distress; no cough, rhonchi, wheezing, or rales. No use of accessory muscles. ABDOMEN: Symmetrical, non-distended, positive hyperactive bowel sounds in all four quadrants, no mass or hepatosplenomegaly. Liver edge is smooth and palpable 1 cm below the right coastal margin. PELVIC/GU/RECTAL: Deferred. EXTREMITIES: Skin warm to the touch, moist and clean, no clubbing cyanosis. No peripheral edema, muscles symmetric, no atrophy, bilateral dorsalis pedis pulse 2+, no deformities or signs of trauma noted. All joints are stable without laxity. There is good range of motion in all extremities. NEURO: Oriented to person, place, and time, cooperative, thought process coherent. Detailed cognitive testing differed. Muscle strength in bilateral upper extremities is rated 3/5 and with unsteady gait, good muscle tone, no abnormal trauma or twitching. Deep tendon reflexes (DTRs) are hyperreflexia, proprioception intact, negative Romberg’s sign, and negative pronator drift. IMPRESSION/PLAN DIFFERENTIAL DIAGNOSES: 1. Subacute Thyroiditis. ICD 10 CODE: E06.1. This is ruled out because this is an inflammation of the thyroid tissue that may be caused by bacteria or a virus; resulting in toxic nodule or toxic multinodular goiter. These causes the thyroid gland to temporarily produce extra thyroid hormone (T4). This is a self-limited thyroid condition associated with a triphasic clinical course of hyperthyroidism, hypothyroidism, and return to normal thyroid function. Thyroid function test: T3 is normal, T4 is increased, and TSH is decreased. Increased ESR. Recurrences are rare (Buttaro, Trybulski, Bailey & SandbergCook, 2013). 2. Pheochromocytoma. ICD 10 CODE: D35.00. Renal effects include sodium retention, increased renin secretion, and reduction of hydrostatic pressure. Cardiovascular effects involve peripheral vasoconstriction and increased cardiac contraction and workload from significant hypertension. Tissue oxygen consumption and gluconeogenesis are also increased. This is ruled out because this is a cathecholamine-secreting tumor of chromaffin (pheochromocytes) cells. Ninety percent are found in the adrenal medulla; others arise intra-abdominally along the sympathetic ganglion chain. The rare incidence of a primary malignant process occurs when the tumor spreads beyond chromaffin tissue. Occurrence is primarily in the middle years. Ten percent are familial. There is abnormal production of epinephrine and norepinephrine by a pheochromocytoma produces multisystem effects (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).

3. Cushings Syndrome. ICD 10 CODE: E24.2. This is cause by excessive cortisol and corticosteroid hormones, either endogenous or exogenous. Endogenous cause of cortisol hyper secretion include pituitary adenomas; other malignancies, such as small cell lung cancer; and adrenal tumors. Exogenous causes are related to the administration of steroids for the management of other chronic diseases. Hypertension, insomnia, and memory and mental health disturbances occurs in 50% of patients. Patient complain of excessive thirst and polyuria owing to glucose intolerance, and they are prone to renal calculi. This is ruled out because Cushingoid sign and symptoms are weakness due to profound muscle wasting; generally, this is not the first symptom that bring the patient to the doctor; impotence or decreased libido is usually the reason. Patients develop a “moon face” and “buffalo hump” with central obesity and thin extremities. Purple striate around the thighs, breast, and abdomen are characteristic of Cushing’s; patients are prone to bruising, acne, and skin infections with poor healing. Changes in mental health are common and range from mood swings to psychosis (Goolsby and Grubb, 2011).

DIAGNOSIS: Graves’ disease. ICD 10 CODE: This is a hypermetabolism disorder that results from autonomous production of thyroid hormone, independent of TSH from the pituitary gland. The first hormonal sign of emerging hyperthyroidism is suppressed TSH. The hyperthyroidism of Graves’ disease results from an immunoglobulin that stimulates the TSH receptor on the thyroid gland, resulting in hypertrophy of the gland and overproduction of thyroid hormone. This thyroid stimulating immunoglobulin can be measured in the patient’s serum as a marker of Graves’ disease activity. Excess thyroid hormone (T4) in the circulation increases metabolic rate, increases activity of the sympathetic nervous system and affects fat and carbohydrate metabolism (Monahan, Sands, Neighbors, Marek, and Green, 2007). Graves’ disease is the most common cause of hyperthyroidism except in patients over 55, in whom multinodular goiter is a more common etiology (Goolsby and Grubb, 2011). This is ruled in because, the most common age is between 20 and 40 years. Signs and symptoms of clinical manifestations include diffuse goiter, nervousness, irritability, tremor, heat intolerance, weakness, tachycardia, palpitation, widened pulse pressure, increased sweating, weight loss, insomnia, frequent bowel movements, menstrual irregularities, exophthalmos, and infiltrative dermopathy (Goolsby and Grubb, 2011). Laboratory test results shows: Free T4 7.8 (normal range 0.9-1.7); free T4 concentration in serum indicates thyroid activity, TSH 0.01 (normal range 0.4-4.5). TSH is the most sensitive screening indicator of overall thyroid function. TSH levels will be low or undetected. Radioactive iodine uptake scan results: 6 hour assessment, 98% and 24 hour assessment 99%; normal value of radioactive iodine uptake is approximately 30%. Radioactive iodine uptake scan that is used to measure the amount of iodine that the thyroid collects from the bloodstream. High levels of iodine uptake is indicative of Graves ’ disease. With Graves’ disease the entire thyroid is involved, so the iodine shows up throughout the gland. It also assess toxic nodules or thyroiditis or the functional status of a nodule. Iodine isotopes I 123, I125, and I131 are concentrated and bound by thyroid tissues…Isotopes I123 is harmless to thyroid cells, and Isotope I131 destroys thyroid cells. They are given in pill or liquid forms. The scan is performed 4 or 24 hours after the administration of I123…the isotopes are

distributed evenly throughout the thyroid gland. Nodules are classified as hot, warm or cold according to the concentration of iodine isotope in the nodule in comparison with the rest of the thyroid gland. Hot nodules are usually but not always benign. Many cold nodules (solid or cystic) are benign; however, most malignant neoplasms also appear as cold nodules… (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013).

PLAN: 1. LAB/DIAGNOSTIC TESTS/EKG: Repeat laboratory assessment in 10 days: Free T4 and TSH. This to verify if thyroxin is decreased. TSH can remain suppressed for up to 3 months after treatment and therefore the Free T4 or Free T4 index must be followed (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013). Liver function test: Abnormal test results is common; elevation of alkaline phosphate, alanine aminotransferase, aspartate aminotransferase, y-glutamyltransferase, and total bilirubin levels can be seen (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013). Baseline CBC with differentials. Agranulocytosis occurs in 0.2% - 0.5 % of patients; it is usually reversible with discontinuation of medication. Patient is informed to discontinue medication and call the office if there are symptoms of infection: fever, pharyngitis (Buttaro, Trybulski, Bailey & Sandberg-Cook, 2013). 2. Repeat EKG to rule out any arrhythmias. 3. Administer long acting Bata blocker; Propanolol (Inderal) 100 mg PO stat and sent eprescription to patient’s preferred pharmacy. It offers prompt relief of adrenergic symptoms such as tachycardia, and tremors, agitation associated with the sympathetic nervous system stimulation. The dose is titrated as the hyperthyroidism is controlled. Nonselective beta blockers such as propranolol, are preferred because they have a more direct effect on hyper metabolism. Alternative to Beta blocker is calcium channel blockers (Baldor, Golding, & Grimes, 2014). Instruct patient to monitor her pulse rate and contact the health provider if the pulse is less than 50 or more than 120 beats/minute. 4. Administer thioamides antithyroid drug: Methimazole (MMI, Tapazole) 10 MG TID PO; first dose now. This inhibit thyroid hormone synthesis by blocking organification. In addition, thiomide medication is believed to be most effective in patients with Graves’ disease; used up to 6 or 12 months and then discontinued. At this time 30% of people are in remission (euthyroid). Inform patient to contact provider if she experiences malaise, nausea and vomiting, jaundice, dark urine, or light-colored stools. 5. Monitoring is for resolution of hyperthyroidism and for development of hypothyroidism. Chedck TSH and T4 levels every 1-2 monthsfor first 6 months after treatment, then every 3 monts for a year, then every 6-12 months ghereafter. Check anti-TSH receptor antibodies at 12 months of treatment to determine possibility of discontinuing medication. 6. Patient education to adhere to both follow-up surveillance and medication regimens is the most important way to achieve a good outcome and promote lifelong health. Prognosis is good with treatment.

7. For corneal protection: Tinted glasses when outdoors, artificial tears, patching or taping the lids at nights. 8. Topical corticosteroid OTC for dermopathy. 9. Advise to dress in light colored and light weight clothing to ease heat intolerance. 10. Educate on managing medication: Beware of drug interactions for example herbal supplements and over the counter medications. This includes remedies for HA, allergies, colds. 11. Informed patient that her Methimazole is a hormone and needs to be taken as prescribed. Educate not to change the dose or stop taking any of the medication, even if she is feeling better, and always talk to the doctor. Refill prescription before they run out. Check the brand and dosage to make sure they are correct. Be sure to ask your doctor and or pharmacist what to do if you miss a dose. 12. Follow up appointment in 5 days and to call the office or 911 if symptoms get worst. 13. Review of plans of care and clarification of agreement with plans of care.

CONCLUSION KB is a 49 year old Caucasian female who presented to the practice with a complaint of tachycardia, anxiety, hyperactivity and insomnia. She informs that she has been having difficulty sleeping at nights for about 3 months, and has gotten worse within the last 3 weeks. She informs that even though she is unable to sleep at nights, she does not feel tired during the day and just want to keep moving. She states that she is very anxious and irritable. She complains of palpitations. She explains that her symptoms has exacerbated within the last week and that she has been having dry mouth, diarrhea and weight loss. The diarrhea started 2 days ago, and she has been having 3 to 4 loose stools each day. She stated that she is constantly hungry even though she eats a large meal at breakfast, lunch and dinner. She explains that he has been experiencing dizziness, but no falls. Patient denies any recent viral illnesses. The patient was diagnosed with Graves’ disease because of the following; Objectives assessment revealed: Pulse 115, Temperature 99.5 F Respiration 22, BP 148/54, Pulse Ox 99% RA, Height 5’5”, Weight 127 lbs, BMI 19.5. Laboratory test results shows: Free T4 7.8 (normal range 0.9-1.7); free T4 concentration in serum indicates thyroid activity, TSH 0.01 (normal range 0.4-4.5). TSH is the most sensitive screening indicator of overall thyroid function. TSH levels will be low or undetected. Radioactive iodine uptake scan results: 6 hour assessment, 98% and 24 hour assessment 99%; normal value of radioactive iodine uptake is approximately 30%. Physical assessment: Eyes with scant amount of tearing and overt periorbital edema with proptosis. Hoarseness is noted. Skin is smooth, velvety. Warm, moist palms. Hair was sticking to her neck from perspiration. Thyroid is enlarged; smooth diffused goiter with 2 palpable nodules of the right and 1 on the left. Muscle strength in bilateral upper extr...