Hypothyroidism SOAP

Clinical SOAP Note: Hypothyroidism
Student’s Name
Institutional Affiliation:

Clinical SOAP Note: Hypothyroidism
Mrs. Reeves is a 67-year-old woman residing in __, __. She is self-referred to the institutions and appears to be a reliable source for her history.
Subjective Component
Chief Complaint: ‘I feel very weak.’
History of Presenting Complaint:
Mrs. Reeves said that she began feeling weak approximately two months before the visit. The weakness affected her performance of daily activities such as household chores. Initially, she would wake up feeling normal with the weakness increasing progressively throughout the day, but as time progressed, she began to wake up feeling weak and fatigued. She did not experience chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or palpitations. She did not experience a cough, wheezing, or hemoptysis.
Since the weakness began, her appetite has also been decreasing. She claims she can only manage to eat one meal a day only when compelled by her husband. Her skin has been drying progressively although she consumes about four glasses of water every day. She has also been experiencing pain in her elbows and knees which with no aggravating factors but relieved slightly by rest. One month ago, she noticed that her hearing was diminishing slowly – her husband had to shout for her to comprehend his statements.
The Patient’s Medical History
In her young years, Mrs. Reeves was admitted for mumps at 10 and chicken pox at 13.

She has no history of scarlet fever or rheumatic fever. She also suffered a stroke when she was 47 and was admitted and treated successfully with no complications. No history of diabetes, hypertension, arthritis.
Surgical History
She underwent an appendectomy at 31 due to acute appendicitis.
Medications
She has paracetamol in her house, which she takes when she experiences mild pain. She often uses it to relieve minor headaches and backaches, which happen about three times monthly.
Allergies
She is allergic to penicillin and cow-milk.
Family-Social History
Her father died at age 65 due to a myocardial infarction. He was a diabetic. Her mother died at 44 due to a car accident. She has no history of chronic illness. She had one sibling, a brother who is still alive aged 71. He is obese and suffers from mild hypercholesterolemia.
She is married to a 70-year-old man. His family has a history of hemophilia; his mother and elder brother were both hemophiliacs although he does not suffer from the condition. They have one son aged 47 who is a known hypertensive. There is no family history of kidney disease, cancer, mental illness, tuberculosis, or epilepsy.
She is retired and spends most of her leisure time at home where she tends to her garden and visits her friends within the neighborhood. Her husband is also retired although he manages a carwash. They live in a three-bedroomed house and use water from the town’s pipeline system. She neither smokes nor drinks alcohol.
Review of Systems
General: Slight weight gain in the past two months; no fever
Gastrointestinal: Mild constipation, empties bowels once a week down from three times weekly, sometimes painful; no abdominal pain, diarrhea, jaundice, melena, hematochezia; no nausea, vomiting, dyspepsia.
Nervous: Mood changes, has become more easily irritable; difficult to maintain attention; no changes in speech and judgment; no headache, dizziness, seizures, syncope; no paralysis, numbness, tingling, tremors.
Urogenital: No hematuria, oliguria, frequency, urgency, dysuria, any flank pain, nocturia, urinary incontinence, hesitancy, terminal dribbling, or urethral discharge.
Objective Component
Mrs. Reeves is modestly tall and built. She appears sickly and needs one to speak louder than usual for her to respond accurately. She is neat, and her hair is well-groomed.
Vital Signs
Height 152 cm, Weight 66 kg, BMI 28.57 (slightly obese), BP 136/98 right arm, supine; 139/98 left arm, supine (normal), heart rate 90 b.p.m (normal), Respiratory rate 18 breaths/minute (normal), Temperature 98.8 Fahrenheit degrees, oral (normal).
Physical Examination
Thorax: Thorax moves symmetrically while breathing, good excursion, lungs resonant, vesicular breath sounds with no additional sounds, diaphragm descent 3.2 cm during inspiration (normal).
Cardiovascular: jugular venous pressure 1.2 cm above the sternal angle with head-of-bed tilted at 30° (normal). Carotid upstrokes brisk, no bruits. Apical beat distinct and tapping, not palpable in the 5th intercostal space, 7cm lateral to the midsternal line. Good S1, S2; no S3 or S4. No systolic or diastolic murmurs.
Neck: Neck is supple. Trachea in the midline. Thyroid isthmus not palpable, lobes not felt. No lymphadenopathy.
Abdomen: No visible distension. Symmetric. No scars or visible skin lesions. No tenderness. No masses. Navel folded inwards. Liver span 8 cm in the right mid-clavicular line, palpable 1.4 cm below the right costal margin. Spleen and kidneys not palpable. No costovertebral angle tenderness.
Hands and Arms: No digital or palmar pallor, no cyanosis, no scars or bruises, paresthesias on fingers.
Hydration: Normal skin turgor, capillary refill < 2 s (normal), moist mucous membranes in the mouth.
Laboratory Findings
Serum TSH: 4.7 milli-units/L.
Serum FT4: 0.4 ng/dL.
Thyroperoxidase antibody: 37 IU/mL.
Thyroglobulin antibody: 25 IU/mL.
Assessment Component
Significant Health Concerns
Low levels of FT4 points towards a suboptimal performance of the thyroid gland (Ajish & Jayakumar, 2012). Due to changes in the thyroid gland which accompany aging, hypothyroidism is more common among the elderly population (Kim, 2017). The most significant health concern is myxedema coma, which presents as fatal changes in neurologic function – it is also more common among the elderly (Fitzgerald, 2017). Health professionals also need to take additional care while performing surgeries on elderly patients with the condition since they are more likely to develop complications such as heart failure, intraoperative hypotension, and various neuropsychiatric and gastrointestinal complications.
Differential Diagnoses
The differential diagnoses for the symptoms and signs presented are:
Hashimoto thyroiditis.
Thyroid lymphoma.
Iodine deficiency.
Euthyroid sick syndrome.
Riedel thyroiditis.
Atrophic chronic thyroiditis
Priorities
Restore normal levels of thyroid hormones.
Investigate inherent causes.
Evaluate for possible complications.
Treat symptoms of the condition.
ICD 9 Code: Code 244
CPT Code: E89.0
Planning Component
Diagnostic Interventions:
The condition is identified effectively by TSH screening followed by the measurement of free T4. Testing for thyroglobulin and thyroperoxidase confirms the diagnosis of Hashimoto thyroiditis, which is due to attack or the gland by these antibodies leading to hypothyroidism.
Therapeutic Interventions:
Replacement therapy:
Treatment of choice is levothyroxine (Papaleontiou & Haymart, 2012). It is important to remember that elderly patients are more sensitive to the administration of exogenous thyroid hormones. The recommended starting dose for patients without cardiac disease is 25 mg/day and 12.5 mg/day in patients with cardiac comorbidity (Papaleontiou & Haymart, 2012). After the evaluation of the cardiovascular tolerance, the daily dose may be increased by 12.5-25 mcg every four weeks until an adequate replacement is achieved and confirmed by serum analysis.
Expected outcomes:
The patient’s symptoms begin to improve in 3-5 days. However, the normal range of thyroid hormones is achieved after several months.
Consultation:
No need for consultation. Refer to the endocrinologist if replacement therapy fails to restore the normal level of hormones or for the management of a patient with coronary artery disease.
Health education:
The patient should be informed that her condition arose from an unpreventable cause and is easily manageable (Bensenor, Olmos, & Lotufo, 2012).
Disposition and health promotion:
Mrs. Reeves shall be asked to report every second month for evaluation of the treatment. She shall be informed of the possible side effects of the replacement therapy and to see a pharmacist is she experienced particular symptoms of overtreatment including tiredness, headaches, tremors, tachycardia, and angina pectoris.
Ethical, Legal, and Geriatric Considerations
The patient shall be treated individually, and his symptoms shall not be shared with anyone else without their permission. She shall be informed of his right to refuse any treatment offered, and informed consent shall be derived for all the adopted interventions. The condition hardly has chronic sequelae; she shall be informed of the possible complications and assigned a physician to call in case of a medical emergency.
Summary
Mrs. Reeves is a 67-year-old lady who presented to the institution with chronic fatigue, arthralgia, poor appetite, and diminished hearing. Physical examination reveals slight weight gain. The laboratory tests confirm a diagnosis of hypothyroidism due to Hashimoto thyroiditis. Treatment of this condition is primarily through long-term replacement therapy; it has a good prognosis especially since she does not suffer from a cardiac condition. She shall be scheduled for follow-up visits to evaluate her response to the treatment.
The Observations Noted: The patient was collaborative throughout the treatment duration. He showed corporation by providing clear symptoms, responding to questions, and adhering prescriptions.
Questions that were raised that demanded further exploration: What is hypothyroidism and what is the lasting clinical solution to this menace. Hypothyroidism is an acute deficiency of the activity of the thyroid gland hence leading to slow mental and physical development. The condition is mostly common in adults and children. The condition is identified effectively by TSH screening followed by the measurement of free T4. Testing for thyroglobulin confirms the diagnosis of Hashimoto thyroiditis, due to attack or the gland by these antibodies leading to hypothyroidism.
Interaction with the Patient: The patient was in a position to relate clinical explanations as pertains to her condition. She exemplified a high level of collaboration and tolerance with the provider – often asking questions regarding the hypothyroidism. Of special concern during our interaction is that the patient showed great courage for recovery and adhered to offered prescription schedules and therapeutic approaches.

References
Ajish, T. P., & Jayakumar, R. V. (2012). Geriatric thyroidology: An update. Indian Journal of Endocrinology and Metabolism, 16(4), 542–547.
Bensenor, I. M., Olmos, R. D., & Lotufo, P. A. (2012). Hypothyroidism in the elderly: diagnosis and management. Clinical Interventions in Aging, 7, 97–111.
Fitzgerald, P. A. (2017). Endocrine disorders. In: Papadakis, M. A., McPhee, S. J., & Rabow, M. W., editors. Current Medical Diagnosis and Treatment. New York: McGraw Hill.
Kim, M. I. (2017). Hypothyroidism in the elderly. In: De Groot, L. J., Chrousos, G., Dungan, K., et al., editors. Endotext. South Dartmouth (MA): MDText.com, Inc.
Papaleontiou, M., & Haymart, M. R. (2012). Approach to and treatment of thyroid disorders in the elderly. Medical Clinics of North America, 96(2), 297-310.