SOAP Note Hypothyroid PDF

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Hypothyroid ...

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Treatment of Hypothyroidism Discussion Prompt Scenario: You are evaluating a 53-year-old white female who wants to talk to you about lab work that she had done recently at “Any Lab Test Now”.   

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She wanted to have lab work done because she was feeling tired and unmotivated. Additionally, she had put on about 15 pounds even though she has been teaching yoga 2-3 times a week for the last few years. The lab results reveal a TSH of 93. She reports her last menstrual period was about 3 years ago. She experienced some menopausal symptoms of hot flashes and night sweats. However, she states they weren’t too much of a problem and those resolved a couple years ago. She denies any difficulty swallowing or neck pain/tenderness. Constitutional exam: 5’5” tall, 154 pounds, BP 145/88, P 60, R 16, Temp 97.2 Neck – nontender, mild goiter with right side of thyroid larger than the left side Heart – regular rhythm without murmur or gallop Lungs – clear Skin – dry on extremities with some flaking noted A slowness of the relaxation phase of the Achilles tendon reflex is noted

Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources. Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Initial post Utilize the information provided in the scenario to create your discussion post. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan). Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A] Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and nonpharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention]

Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate - collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and nonpharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making

Subjective (S): The patient is a 53-year old white female. She came in to the office to discuss her results from lab work she had done at “Any Lab Test Now”. The results revealed a TSH level of 93. The patient went to have lab work done due to herself feeling tired and unmotivated. She has gained about 15 pounds in the last year despite an active lifestyle and teaches yoga classes 2 to 3 times a week. Patient states her last menstrual period was about 3 years ago. She notes she did have symptoms of menopause such as hot flashes and night sweats, but they were not too much of a problem. The had resolved a couple of years ago. Patient denies any difficulty swallowing or any pain or tenderness in her neck. Objective (O): Patient is 5’5” and 154 pounds. BP is 145/55, RR 16, Temp 97.2. On assessment her neck has a nontender, mild goiter on the right side of her thyroid which is larger than the left side. The heart has a regular rhythm with no murmur or gallop noted. Patients’ lungs are clear. Patients’ skin is dry and flaky on the extremities. Also noted is a slowness of relaxation of the Achilles tendon reflex. Assessment (A): Based on the patient TSH level and palpable goiter, this patient seems to be suffering from hypothyroidism. Autoimmune thyroid disease or Hashimoto is the most widespread cause of hypothyroid disease in the United States of America. (Arcangelo, Peterson, Wilbur, & Reinhold, 2017). It is the product of the permeation of the thyroid by white blood cells, which leads to increasing fibrosis and a reduced function of the thyroid gland. (Arcangelo et al., 2017). The patient may have an enlarged thyroid gland and have normal thyroid functions primarily; and then an overactive antibodies. (Arcangelo et al., 2017). Plan (P): The lone treatment for thyroid disease is to substitute with thyroid hormone. (Arcangelo et al., 2017). I would recommend to retest the thyroid levels and to have an ultrasound of the thyroid gland to make sure it is not any sort of nodules or tumors that is causing the elevated TSH levels.

Therapeutics: The objective of treatment is to revert the patient to a TSH span of 0.5 to 4.0mIU/mL. (Arcangelo et al., 2017). Medication therapy for thyroid disease is generally permanent; except for patients who have thyroiditis from pregnancy or acute hypothyroid. (Arcangelo et al., 2017). Primary care clinicians’ must start the patient on a replacement hormone for thyroid disorders knows as levothyroxine. (Arcangelo et al., 2017). Levothyroxine is easily soaked up by the gastrointestinal system. (Arcangelo et al., 2017). It can take 6-8 weeks of medication use to get the TSH levels in the appropriate range, it may take patients a week or longer to alleviate their indicators of hypothyroidism. (Arcangelo et al., 2017). Education: Patients with hypothyroidism will need to take levothyroxine for their lifetime. (Arcangelo et al., 2017). It can take 2 to 4 weeks for patient to notice an improvement in their symptoms. (Arcangelo et al., 2017). It is important for frequent TSH levels to be checked to make sure that mediation therapy is working and an unwavering TSH level is accomplished, and then should be checked again once a year. (Arcangelo et al., 2017). Consultation: Nodules on the thyroid are widespread, found in about 5% of patients with ultrasound exams. (Arcangelo et al., 2017). Most of the time, these nodules are not cancerous and they grow slowly, 1,900 patients die annually in the US due to thyroid cancer. (Arcangelo et al., 2017). I would recommend this patient have an ultrasound of her thyroid and then to follow-up with an endocrinologist to monitor and manage her thyroid disease. Reference: Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A. (20161108). Pharmacotherapeutics for Advanced Practice, 4th Edition [VitalSource Bookshelf version]. Retrieved from vbk://9781496374066...