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SOAP Note

Project Concert ID: 3116867

Student: Brenda Garcia

United States University

FNP 596 Sect4 Primary Healthcare of Chronic Client/Families Across the Lifespan

Professor: Dr. Cherika Gadson

08/26/2024
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Week 4 Endocrine SOAP

SUBJECTIVE:
ID: J.C, DOB:08/06/1958, age 66, Asian female presents to the clinic unaccompanied and
appears to be a reliable historian.

Subjective:
CC: “I’m feeling always tired.”

66-year-old Asian female presents to the clinic unaccompanied. Complaining of feeling tired,
gaining weigh without being able to lose weight regardless dieting and exercise as she normally
would. Reports to be walking up to three times per week and following a well-balanced diet.
Reports having constipation and having less bowel movements per week than she normally
would. Patient also reports feeling more sensitive to cold even when layering up on a 75-degree
temperature room. No significant medical history.

Past Medical History:

 Medical problem list:
Covid-19 positive in 2023.
 Surgical:
Wisdom teeth extraction as a child (unknown years)
Allergies:
No known drug allergies, seasonal allergies or food allergies.
Medications:
1. Multivitamins Over the counter, one tablet daily
2. No prescription medication orders.
Vaccinations:
Received all childhood vaccines,
Yearly flu shot; last flu shot on February, 2024.
Covid: Completion of “Moderna series” in 2021
Received Tdap in 2021
Shingles vaccine, 2022.
Tetanus and pertussis, 2020.
PCV 13 2020

Social History:
Married, retired middle school teacher.
Lives at home with husband, daughter, and grandson
Walks 3 times a week up to a mile each walk, Participates in a book club reading.
Other:
Resides in a one-story home with daughter.
Does not own a gun, feels secure at home, wears seat belt.
Spirituality: None
Diet: Home-cooked meals 6/7 days a week
Chemical history:
Denies tobacco, vape, cigar, alcohol, or illicit drug use.
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Drinks two cups of coffee daily.

Family History
Mother: Age 76-Hypothyroidism and diabetes (alive)
Father: Age78-Cardiac arrhythmia, asthma (alive)
Grandmother maternal: age 92- unknown medical history (deceased)
Grandfather maternal: age 89-unknown medical history (deceased)
Grandmother paternal: age 88- unknown medical history (deceased)
Grandfather paternal: age unknown- unknown medical history (deceased)

ROS:
Constitutional: Denies fever, chills, weakness. Reports weight gain 10+ lb. in 2 months, fatigue,
constipation 1-2 bowel movement per week. Denies having been around anyone sick.
C/V: Denies chest pain, tightness, palpitations.
Resp: Denies shortness of breath, cough, or wheezing.
GIT: reports 1-2 bowel movements per week, “used to have one daily.”
Musculoskeletal: She denies having pain or swelling in the joints.
Neuro: Denies headache, dizziness, weakness, numbness, or tingling. Denies feeling sad or
having mood changes.
Endo: Reports gaining weight, feeling fatigued, and cold.
Hema/Lym: Denies having easy bruising or bleeding.

Objective
VS: P: 60 BP: 110/60 RR: 14 T: 97.4F SpO2: 98% on RA, Pain: 0/10 Ht: 63 in Wt: 176 lbs BMI:
31
General: well groomed, in no acute distress.
Neuro: AAOx4. Appropriate behavior, answers all questions. Cranial nerves II-XII grossly intact.
Cardio: RRR. Crisp S1 S2 present, no clicks, murmurs, or gallops. No peripheral edema, JVD, or
carotid bruit.
Thorax and lungs: Thorax is symmetric with even expansion. Respirations are even and
unlabored. No use of accessory muscles. Clear lung sounds bilaterally upon auscultation.
GU: Abdomen soft and non-tender, no organomegaly, bowel sounds are hypoactive.
Skin: Dry and cool when touched, no open wounds or deformities noted.
EarsNose/Throat/mouth: Minimal cerumen, tympanic membrane is flat, gray, and translucent
bilaterally (BL). Nostrils are pink moist no discharge, septum is midline. non-tender cervical
area, no lymph nodes palpable. Non-enlarged Thyroid palpated; trachea is midline. Tonsils are
pink and moist, no swelling or white patches, gums are pink and moist, no open wound or
redness, upped and lower dentures present and well fitted.

Assessment:
Differential Diagnoses
1. Hypothyroidism (E03.9 - Unspecified Hypothyroidism)
Reasoning: The patient's symptoms—fatigue, weight gain, constipation, and cold
intolerance—are classic indicators of hypothyroidism. Given the family history of
hypothyroidism, this diagnosis is strongly supported.
2. Anemia (D64.9 - Anemia, Unspecified)
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Reasoning: Anemia can cause fatigue and weakness, symptoms that the patient is
experiencing. The patient's dietary habits and lack of other apparent causes for fatigue
warrant testing for anemia, particularly iron deficiency or vitamin B12 deficiency, but
does not explain the weight gain and cold intolerance.
3. Menopausal Syndrome (N95.1 - Menopausal and Postmenopausal Disorders)
Reasoning: Although the patient is past the typical age for menopause, postmenopausal
symptoms can persist, including fatigue, weight gain, and sensitivity to cold. The absence
of other typical menopausal symptoms such as hot flashes and mood swings makes this
diagnosis less likely but still worth considering.

Final Diagnosis: Hypothyroidism (E03.9)

Plan:
Diagnostic Plan: TSH and Free T4 baseline and then every two weeks after starting
medication to monitor thyroid function (Wilson et al., 2021). CBC and iron studies to
rule out anemia as a contributing factor to fatigue (Doshi & Aslani, 2021).

Pharmacological Plan: Levothyroxine: Start with a low dose of 25 mcg daily by mouth
30-60 minutes before breakfast and increase it depending on thyroid function tests and
the patient's response (Wilson et al., 2021; Biondi & Wartofsky, 2014).

Therapeutic Plan: Diet: Encourage a balanced diet rich in fruits, vegetables, lean
proteins, and whole grains to support overall health and weight management.
Specifically, advise moderate consumption of shellfish and adequate intake of selenium
and zinc for thyroid health (Papaleontiou & Haymart, 2019). Exercise: Recommend
regular physical activity, such as 30 minutes of brisk walking, cycling, or swimming most
days of the week, to improve energy levels and general well-being (Wilson et al., 2021).

Stress Management: Suggest stress reduction techniques like mindful meditation, deep
breathing exercises, or engaging in enjoyable activities to mitigate the impact of stress on
thyroid function (Wilson et al., 2021).
Referrals:
Endocrinologist: Given the diagnosis of hypothyroidism, especially if there are
complexities in managing the condition or if the patient has other endocrine disorders
(e.g., diabetes, given her family history), a referral to an endocrinologist may be
beneficial.

Education:
Thyroid Hormone Education: Explain the role of thyroid hormones in regulating
metabolism, energy levels, and various bodily functions (Wilson et al., 2021).
Medication Adherence: Emphasize the importance of taking levothyroxine daily, ideally
first thing in the morning, on an empty stomach, at least 30 minutes before breakfast or
other medications (Wilson et al., 2021).
Dietary Considerations: Provide dietary guidance to support thyroid health, including
avoiding excessive iodine intake and ensuring adequate selenium and zinc (Papaleontiou
& Haymart, 2019).
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Follow-Up Plan:
Initial Follow-Up Visit (4-6 weeks):
Assess the patient's response to thyroid treatment.
Review thyroid function test results to evaluate thyroid hormone levels.
Adjust levothyroxine dosage, if necessary, based on thyroid function tests and clinical
response (Wilson et al., 2021).
Address any concerns or questions related to medication adherence, symptom
management, or lifestyle adjustments.
Reinforce the importance of regular monitoring and adherence to the treatment plan.

Subsequent Follow-Up Visits (every 6-12 months):

Continue monitoring thyroid function tests (TSH and Free T4 levels) to ensure thyroid
hormone levels remain within the target range.
Evaluate the patient's symptoms and overall health.
Assess medication adherence and check for any potential side effects.
Address any emerging or recurring health issues, symptoms, or changes (Wilson et al.,
2021).
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References

Biondi, B., & Wartofsky, L. (2014). Treatment with thyroid hormone. Endocrine Reviews, 35(3),
433–512. https://doi.org/10.1210/er.2013-1083

Doshi, S. M., & Aslani, A. (2021). Anemia in the elderly: A public health crisis in hematology.
Hematology Reports, 13(3), 49–57. https://doi.org/10.3390/hemato13030008

Papaleontiou, M., & Haymart, M. R. (2019). Approach to and treatment of thyroid disorders in
the elderly. Medical Clinics of North America, 103(3), 535–552.
https://doi.org/10.1016/j.mcna.2018.12.008

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and
treatment. American Family Physician, 103(10), 605–613.
https://pubmed.ncbi.nlm.nih.gov/33983002/