Focused Thyroid Exam – Best Sample Solutions on Focused SOAP Note(2022)

This article covers a Focused Thyroid Exam: Episodic/Focused SOAP Note about Chantal, a 32-year-old female, comes into your office with complaints of “feeling tired” and “hair falling out”.

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Focused Thyroid Exam

Chantal, a 32-year-old female, comes into your office with complaints of “feeling tired” and “hair falling out”. She has gained 30 pounds in the last year but notes markedly decreased appetite. On ROS, she reports not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.

Consider what history would be necessary to collect from the patient.

Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\\\’s condition. How would the results be used to make a diagnosis?

Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

…

Solution

Episodic/Focused SOAP Note

 Patient Information: JQ, 32 year old Hispanic female

S.

CC (chief complaint) “I have been feeling tired ‘and ‘hair falling off’.

HPI: JQ, a 32 year old Hispanic female complains constantly feeling fatigued and has noticed her hair is falling off. She also complains of adding some 30 more pounds over the last 12 months despite her decreased appetite. The patient reports not sleeping well and feels cold always. She continues to enjoy her hobbies and denies being depressed.

Current Medications: She is presently not taking any prescription medication or even over the counter drugs.

Allergies: None that the patient knows of.

PMHx: Has had no surgeries.

            Hospitalized five years ago for gastrointestinal disorders

            Denies any chronic medical condition

            No history of psychiatric illness.

            Had mumps and chickenpox at 9 years

Immunizations: Patient cannot definitely tell and no records are available in this area.

Medications: Multivitamin iron 1 tablet daily.

                        Integra F 1 capsule daily

Soc Hx:  Housewife since for all her married life of 10 years. Relates well her husband Smith, who works as a grocer in the community. Has no substance abuse issues. Both have two children a boy and a girl aged 9 and 3 years respectively. Both health although the boy had to take iron supplements between ages 3 and 5 years. JQ actively participates in the community volunteer activities.

Fam Hx:  Mother, 56 years and has had Myocardial infarction, hypertension and is obese

                        Father 61 years chronic knee pain.

                        Brother with a history of substance abuse.

ROS

GENERAL:  Added 30 pounds over the last year. Has cold fevers

HEENT:  No history of head trauma, aches or seizures. Eyes have no change in vision, Ears have no vertigo or tinnitus, Nose has no epistaxis, and Mouth and throat have no sores or pain.

 SKIN:  No rashes but has experienced hair loss to date

 CARDIOVASCULAR:  No pain in the chest, orthopnea or PND.

RESPIRATORY:  No breath shortness, cough or sputum.

GASTROINTESTINAL: .No abdominal pain or blood, no vomiting or nausea.

GENITOURINARY:  No Burning on urination.

NEUROLOGICAL:  No headache, No dizziness, syncope, paralysis, ataxia

MUSCULOSKELETAL:  No back pain, joint pain or stiffness.

HEMATOLOGIC:  Has a history of anemia but no transfusions

 LYMPHATICS:  No enlarged nodes. No history of splenectomy.

PSYCHIATRIC:  No history of depression or anxiety.

ENDOCRINOLOGIC; denies sweating

ALLERGIES:  No history of asthma, hives, eczema or rhinitis.

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O.

Physical exam

VS: BP 157/87 P55 R15 Weight 181# Height 5’1/2”

General Appearance: healthy-appearing, well-nourished, and well-developed

Cardiovascular— Rate 55 with no murmurs S3 or S4 occasional skipped beat

Respiratory-mild reduced breath sounds, chest clear to auscultation.

Gastrointestinal—abdomen BS present, soft without masses.

Pulmonary— No crackles, no wheezing and no rhonchi.

Diagnostic Tests

• Full blood count (FTC)
• Hormone levels test

World Health Organization defines anemia as a condition when\re the RBC or their oxygen carrying capacity is insufficient (Alli et al, 2017). It can be classified depending on the RBC characteristics like size, chromia, and morphology or based on the underlying morphology like bone marrow aplasia.

A.

Differential Diagnoses

• Iron deficiency anemia (confirmed)
  • According to Kabotarizadeh et al (2019) microcytic anemia clinically manifests as the presence of trifling, hypochromic, red blood cells in a peripheral blood smear. This was confirmed after the blood smear indicated that JQ had a low MCV of less than 83micorn. JQ also admits she bleeds heavily during her menses.
• Megaloblastic bone marrow (refuted)
  • Consists of blood disorders whose defining characteristic is the presence uncharacteristic of the morphological appearance of the developing RBCs in the bone marrow. Its cause is deficiency in Cobalamin or folate (Srikanth, 2016). This was ruled out because the smear after bone marrow aspiration did not show a megaloblastic nuclei larger than normblastic nuclei. The patient was also not having any liver disease.
• Trauma anemia (refuted)
  • The patient denied having had any accident that count have led to excessive bleeding or a medical operation like surgery that could have led to internal bleeding. Neither does the patient report gastro intestinal issues.
• Anemia- induced hair loss (confirmed) (androgenetic alopecia)
  • Considering that research has connected iron deficiency to hair loss in women, this is confirmed in the present case. Evidence also indicates that iron deficiency hair loss does not scare the hair follicles. Asz-Sigall et al (2016) also notes dermoscopy is an important complementary method that helps skin specialists to diagnose scalp disorders.
• Alopecia areata (refuted)
  • Alopecia areata is an autoimmune disorder that manifests through the patient’s immune system attacking the hair follicles (Ramos & Miot, 2015). This was refuted because there are no round smooth patches of baldness in JQ.

References

Alli, N., Vaughan, J., & Patel, M. (2017). Anaemia: Approach to diagnosis. SAMJ: South African Medical Journal, 107(1), 23-27.

Asz-Sigall, D., González-de-Cossio-Hernández, A. C., Rodríguez-Lobato, E., Ortega-Springall, M. F., Vega-Memije, M. E., & Guzmán, R. A. (2016). Differential diagnosis of female-pattern hair loss. Skin appendage disorders, 2(1-2), 18.

Kabootarizadeh, L., Jamshidnezhad, A., & Koohmareh, Z. (2019). Differential diagnosis of iron-deficiency anemia from β-thalassemia trait using an intelligent model in comparison with discriminant indexes. Acta Informatica Medica, 27(2), 78.

Phillips, T. G., Slomiany, W. P., & Allison, R. (2017). Hair loss: common causes and treatment. American family physician, 96(6), 371-378.

Ramos, P. M., & Miot, H. A. (2015). Female pattern hair loss: a clinical and pathophysiological review. Anais Brasileiros de Dermatologia, 90(4), 529-543.

Srikanth, S. (2016). Megaloblastic anemia-A clinical spectrum and a hematological profile: The day-to-day public health problem. Medical Journal of Dr. DY Patil University, 9(3), 307.

Question

Case study 2 : 

Last names beginning with J to Q

Focused Thyroid Exam

Chantal, a 32-year-old female, comes into your office with complaints of “feeling tired” and “hair falling out”. She has gained 30 pounds in the last year but notes markedly decreased appetite. On ROS, she reports not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.

• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient\\\’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.

As you continue, customnursingassignments.com has the top and most qualified writers to help with any of your assignments. All you need to do is place an order with us. (Focused Thyroid Exam)

The Assignment

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient\\\’s differential diagnosis and justify why you selected each.

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