NURS 6512 Episodic/ Focused SOAP Note Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

NURS 6512 Episodic/ Focused SOAP Note Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Case Study 2: Focused Thyroid Exam

Patient Information:

Initials: C.M

Age: 32 years

Sex: Female

Race: African American

Subjective:

Chief Complaint (CC): “I am feeling tired and my hair is falling out.”

History of Present Illness (HPI): C.M is a 32-year-old African American female patient presenting with the chief complaints of feeling tired and experiencing hair loss. She first noticed her hair falling out from her scalp 12 weeks ago, occurring in patches while brushing her hair. The symptom of fatigue started approximately eight weeks ago, following the hair loss. C.M. also reports gaining about 30 pounds in the past year, despite a significant decrease in appetite. She states that fatigue occurs during light tasks, climbing stairs, and short-distance walking. Hair loss happens during shampooing or brushing. Fatigue worsens with activity but improves with rest, and any friction on the scalp triggers hair fall. She has tried hair treatments to stop the hair loss, but they have been ineffective.

Current Medications: Vitamin C supplements, 1 tablet per day, long-term use.

Allergies: No known food or drug allergies.

Past Medical History (PMHx): Immunizations are up-to-date. Last Tetanus shot was 16 months ago. No history of chronic illnesses. Had an Incision & Drainage procedure in 2012 due to an abscess on the left thigh.

Social History (Social Hx): C.M is a paralegal working in a law firm and resides in Baltimore, Maryland, with her husband and seven-year-old daughter. Her hobbies include writing articles, reading novels, and skiing. She admits to consuming alcohol, specifically vodka (3-4 glasses) on weekends but denies smoking or using illicit drugs. Her physical exercise routine includes brisk walks for about 20 minutes when going to work and swimming on weekends. She sleeps approximately 7 hours a day and has three balanced meals. C.M. reports attending annual well-exams, wearing seat belts while driving, and having smoke detectors.

Cardiovascular Shadow Health Self-Reflection example

Family History (Family Hx): The maternal grandmother had colorectal cancer diagnosed at the age of 57 years. The paternal grandfather had renal failure. Mother had breast cancer successfully treated four years ago. Siblings are alive and well. Her daughter has eczema.

Review of Systems (ROS):

GENERAL: Reports weight gain and fatigue with low energy levels. Denies chills, malaise, or fever.

HEENT:
– Head: Reports hair loss. Denies headache.
– Eyes: Denies visual changes or excessive lacrimation.
– Ears: Denies hearing loss, ear discharge, or tinnitus.
– Nose: Denies sneezing, congestion, runny nose, or epistaxis.
– Throat: Denies sore throat.

SKIN: Denies skin color changes, rashes, lesions, or itching.

CARDIOVASCULAR: Reports fatigue on exertion. Denies chest pain, pressure, or discomfort. No edema, shortness of breath, or palpitations.

RESPIRATORY: Denies cough, sputum production, or shortness of breath.

GASTROINTESTINAL: Reports decreased appetite. Denies nausea, vomiting, abdominal discomfort, bowel changes, or blood in the stool.

GENITOURINARY: Denies pelvic pain, abnormal vaginal discharge, painful urination, urinary frequency/urgency, or blood in the urine. Last menstrual period: 06/18/2020.

NEUROLOGICAL: Denies headache, syncope, dizziness, muscle weakness, tingling sensations in the extremities, or loss of smell/taste sensation.

MUSCULOSKELETAL: Denies muscle pain, limitations in movement, joint pain, or stiffness.

HEMATOLOGIC: No history of anemia, easy bleeding or bruising, or blood transfusion.

LYMPHATICS: No history of inflamed lymph nodes or splenectomy.

PSYCHIATRIC: Reports sleeping disturbances. Denies a history of mental disorders and the presence of suicidal ideations.

ENDOCRINOLOGIC: Reports cold intolerance. Denies excessive thirst or hunger, increased sweating, or increased urine production.

ALLERGIES: No history of allergies.

Objective:

Physical Exam:

Vital signs:

– Blood Pressure (BP): 110/68 mm Hg
– Pulse Rate (PR): 68 beats per minute
– Respiratory Rate (RR): 20 breaths per minute
– Temperature (Temp): 97.3°F

Height (Ht.): 5’4″
Weight (Wt.): 167 pounds

HEENT:

– Head: Normocephalic and atraumatic. Hair is black with patches of hair loss, appearing coarse and straw-like.
– Eyes: Sclera is white; Pupils equal, round, and reactive to light (PERRLA).
– Ears: Tympanic membranes intact.
– Sinuses: Non-palpable.
– Nose: Nasal septum is well-aligned.
– Throat: Tonsillar glands are non-inflamed.

Neck: Lymph nodes non-palpable; Trachea is midline. Thyroid gland is nodular on palpation.

Respiratory: Rhythmic and smooth respirations. Lungs clear on auscultation bilaterally.

Cardiovascular: Capillary refill time is 2 seconds. No neck vein distensions or edema. Regular rate and rhythm (RRR), with S1 and S2 heart sounds present. No gallop sounds or systolic murmurs.

Integumentary: Skin is dry. No hypo/hyperpigmentation, skin rashes, or lesions.

Diagnostic Results:

1. Complete Blood Count (CBC) – To evaluate Hemoglobin and hematocrit levels, red blood cell count, and white blood cell count. Low hemoglobin, hematocrit, and red blood cell count can lead to fatigue and cold intolerance. White blood cell count helps determine the presence of infection.

2. Thyroid-stimulating hormone (TSH) Test – A TSH test is used to measure TSH levels. Elevated TSH levels are associated with Hypothyroidism, while decreased TSH levels are indicative of hyperthyroidism.

Assessment (A): Differential Diagnoses:

1. Hypothyroidism – Hypothyroidism is characterized by low levels of thyroid hormone production. Symptoms include fatigue, hair loss, weight gain, and cold intolerance, among others. Physical findings may include an enlarged thyroid gland.

2. Anemia – Anemia is characterized by a reduction in red blood cell proportion, leading to symptoms such as weakness, fatigue, and cold intolerance. Physical findings can include skin pallor.

3. Non-toxic Goiter – Non-toxic goiter is thyroid gland enlargement without changes in thyroid function. Symptoms can include difficulty swallowing and hoarseness. Physical findings may reveal a palpable thyroid gland.

4. Hashimoto’s Thyroiditis – Hashimoto’s thyroiditis results from inflammation of the thyroid gland, leading to symptoms like fatigue and hair loss. Physical examination may reveal a firm, rubbery thyroid gland.

5. Addison Disease – Addison disease is characterized by primary adrenal

insufficiency, leading to symptoms such as fatigue and weight loss. Physical findings may include skin hyperpigmentation.

Justification for Diagnoses:

Hypothyroidism is the priority diagnosis based on the patient’s positive findings of fatigue, hair loss, weight gain, and cold intolerance. Anemia is considered a differential diagnosis but is less likely due to the absence of skin pallor. Non-toxic goiter is included as a possibility due to the palpable thyroid gland, although other symptoms are not evident. Hashimoto’s thyroiditis is considered, but specific symptoms are lacking. Addison Disease is included but less likely due to the presence of weight gain, which is not typical for Addison’s.

Reference:

Turner, J., Parsi, M., & Badireddy, M. (2020). Anemia. In StatPearls [Internet]. StatPearls Publishing.

The Assignment

Utilize the Episodic/Focused SOAP Template to compose an episodic/focused note concerning the patient in the allocated case study, utilizing the provided episodic/focused note template in the Week 5 resources. Present evidence from the literature to substantiate diagnostic tests appropriate for each case. Enumerate five distinct potential conditions for the patient’s differential diagnosis and provide justifications for your selections.

Anemia

Anemia denotes a decrease in the proportion of red blood cells (Turner, Parsi & Badireddy, 2020). Indications of Anemia encompass weakness, fatigue, cold intolerance, lethargy, restless legs, shortness of breath upon exertion, chest pain, reduced exercise tolerance, and Pica (Turner, Parsi & Badireddy, 2020). Frequently observed physical manifestations in Anemia consist of cool skin, tachypnea, hypotension, conjunctival pallor, glossitis, tachycardia, and a systolic murmur.

Anemia stands as a probable diagnosis based on a positive history of fatigue, tiredness, and cold intolerance. Nevertheless, there are no findings of Anemia symptoms such as pallor, shortness of breath, systolic murmur, or tachypnea, thereby excluding Anemia as the primary diagnosis.

Non-toxic Goiter

Goiter signifies the enlargement of the thyroid gland. Non-toxic goiter denotes thyroid gland enlargement without any disruption in thyroid function (Alkabban & Patel, 2020). The enlargement may manifest as either diffuse or localized growth. The goiter has the potential to exert pressure on the upper trachea, laryngeal nerves, and esophagus, yielding symptoms such as dysphagia, shortness of breath, and voice hoarseness owing to mechanical compression of laryngeal nerves. Physical examination findings comprise central neck swelling that is either smooth or nodular, and the mass shifts during swallowing (Alkabban & Patel, 2020). The goiter can lead to tracheal deviation or retrosternal extension.

Non-toxic goiter emerges as a plausible diagnosis based on positive findings of a palpable nodular thyroid gland. Nevertheless, the patient lacks additional indicators of non-toxic goiter, thus rendering it an improbable diagnosis.

Hashimoto’s Thyroiditis

Thyroiditis denotes inflammation of the thyroid gland (Pyzik et al., 2015). It culminates in abnormally elevated or diminished levels of thyroid hormones in the bloodstream. Hashimoto’s Thyroiditis ensues from the immune system attacking the thyroid gland, inciting inflammation and damage (Pyzik et al., 2015). As the thyroid gland undergoes destruction over time, it becomes incapable of producing adequate thyroid hormone. Hashimoto’s Thyroiditis begets symptoms characteristic of an underactive thyroid gland, such as weariness, weight gain, and dry skin (Pyzik et al., 2015). Distinct symptoms of Hashimoto thyroiditis involve the sensation of fullness in the throat, painless thyroid enlargement, fatigue, sore throat, and transient neck pain (Pyzik et al., 2015). Typically, a firm, rubbery thyroid gland is discernible upon physical examination.

Hashimoto’s Thyroiditis constitutes a differential diagnosis predicated on relevant positive findings of fatigue, weight gain, dry skin, and a palpable nodular thyroid gland. Nevertheless, the patient does not exhibit specific symptoms characteristic of Hashimoto’s Thyroiditis, which diminishes its likelihood as a diagnosis.

Addison Disease

Addison disease characterizes primary adrenal insufficiency. It ensues from bilateral adrenal cortex destruction, leading to diminished production of adrenocortical hormones such as aldosterone, cortisol, and androgens (Bornstein et al., 2016). Symptoms associated with Addison disease encompass fatigue, weight loss, generalized weakness, dizziness, anorexia, nausea, vomiting, abdominal pain, tachycardia, and postural hypotension (Bornstein et al., 2016). The condition is often accompanied by diffuse hyperpigmentation of the skin and mucous membranes, primarily in sun-exposed areas, as well as reduced body hair (Bornstein et al., 2016). Other notable physical findings encompass dehydration and refractory hypotension.

Pertinent positive findings for Addison disease encompass fatigue, reduced appetite, and hair loss. Nevertheless, the patient has experienced weight gain, which discounts Addison as the primary diagnosis.

References

Alkabban, F. M., & Patel, B. C. (2020). Non-toxic Goiter. In StatPearls [Internet]. StatPearls Publishing.

Bornstein, S. R., Allolio, B., Arlt, W., Barthel, A., Don-Wauchope, A., Hammer, G. D., Husebye, E. S., Merke, D. P., Murad, M. H., Stratakis, C. A., & Torpy, D. J. (2016). Diagnosis and Treatment of Primary Adrenal Insufficiency: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 101(2), 364–389. https://doi.org/10.1210/jc.2015-1710

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. Lancet (London, England), 390(10101), 1550–1562. https://doi.org/10.1016/S0140-6736(17)30703-1

Pyzik, A., Grywalska, E., Matyjaszek-Matuszek, B., & Roliński, J. (2015). Immune Disorders in Hashimoto’s Thyroiditis: What Do We Know So Far? Journal of Immunology Research, 2015, 979167. https://doi.org/10.1155/2015/979167

Turner, J., Parsi, M., & Badireddy, M. (2020). Anemia. In StatPearls [Internet]. StatPearls Publishing NURS 6512 Episodic/ Focused SOAP note Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat.