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SOAP Note S: SUBJECTIVE DATACC:I feel very tired, have been sweating a lot, my heart is racing and I have lost about 40 pounds in the last one month. HPI: 19 year old supermarket cashier who was first seen on 2/15/19 and reported feeling easily fatigued with associated history of excessive sweating, palpitations and weight loss of 40 pounds over the past month. She had blood work done on that day -02/15 /19 (CMP, CBC, HbA1C, TSH, T3, T4, Lipids). She returned for follow up visit and to review her labs. Her labs values were also repeated on 02/19 and she presented today for review of her labs and to see the in house Endocrinologist. Her lab vales are shown below.LAB VALUES02/15/201902/19/2019TSH (UIU/ML)< 0.010<0.010T4FREE T4 (NG/DL)>7.774.88FREE T3 (PG/ML)15.8THYROID PEROXIDASE7 IU/MLT- UPTAKE 47.8MCV78.6Hemoglobin 13On this visit, she still reports excessive sweating, palpitations, intermittent hand tremors and nervousness. Patient states that she is still able to wok and performs her required daily activities. She has not taken any measures to try to relieve her symptoms. She is not on any current medications and had no known allergies.PMH:Patient has no known past medical history. PSH:Patient has no known surgical history FH: Both parents are deceased. Patient lives with her maternal aunt.Father: hypertension Mother: hypertension SHShe works as a cashier at a local supermarket. She denies drinking, smoking or using illicit drugs. She denies being sexually active. ROSConstitutionalPatient easily fatigued general malaise Denies fever or chills. Unintentional weight loss of 40 pounds in a month.EyesDenies vision problemsHead, Ears, Nose, Mouth, ThroatDenies history of head injury, hearing is good, no tinnitus, and infections. Denies sinus problems, sore throat or hoarseness.CardiovascularDenies chest pain, has palpitationsRespiratoryDenies shortness of breath, or coughGastrointestinal Denies abdominal pain, nausea, vomiting and diarrhea. Denies loss of appetite or polyphagiaGenitourinaryDenies dysuria, frequency, hematuria, polyuria and flank pain.MusculoskeletalDenies joint or muscle pain or swelling IntegumentaryDenies rash, new moles or other changesNeurologicalDenies weakness or numbness. Intermittent tremors to both hands.PsychiatricDenies mood changes, memory problems.EndocrineEasily fatigued, excessive sweating, heat intolerance, excessive weight loss.Hematologic/lymphaticDenies anemia, easily bruising/bleedingAllergic/immunologicDenies allergiesO: OBJECTIVE DATAVITALS:BP 120/77HR 112RR 20Temp 98.8Ht 5’ 8”Wt 145lbBMI 22.7Pain 0/10MEASUREMENTS:Head Circumference:Length:AGE SPECIFIC FINDINGS:PHYSICAL EXAM:General AppearanceMiss Tajada is a well – groomed teenage that looks her reported age. She is alert, displays no signs of cute distress. HeadHair of average texture, scalp atraumatic, no lesions or tendernessENT, MouthEyes-no proptosis, pupils equal and reactive to light and accommodation, anicteric, not pale. Ears-Left and right auditory canal normal, tympanic membrane grey and translucent. Nose- mucosa pink, septum midline, throat- tonsils present, no redness, no swelling, uvula and pharynx – no lesion present, no redness or hoarseness. Oral mucosa- moist and pink. Good dentition and gums. CardiovascularS1, S2 heard on auscultation, no murmurs present. Tachycardia, Carotid up stroke normal without bruits. PMI – normal size, palpable in 5th ICS, at the MCL.RespiratoryLungs resonant. Breath sounds vesicular with no added soundsGIAbdomen soft, non-distended, bowel sounds normal at all quadrants. No tenderness, no hepatomegaly or splenomegaly.GUNo polyuria, frequency or dysuriaMusculoskeletalGood range of motion in hands, wrist, elbows, shoulders, wrist, elbows, shoulders, hip, knee and ankles. SkinSkin warm to touch, no discoloration, nails without clubbing.NeurologicalAlert and orientated to person, place, time. Cranial nerves: II to XII intactPsychiatricWell groomed. Mood appropriate. Answers questions appropriatelyEndocrineNeck supple. No swollen glands. Trachea midline. Thyroid gland -no swelling, mass or nodules on palpation. No thrill and bruits on auscultation Diagnoses (prioritized) and ICD 10 code:E05.90: Thyrotoxicosis (Graves disease) R71.8: Microcytosis D56.9: Probable Thalassemia CPT codes for example, 93005:?EKG85025: CBC with differentials80053: CMP84443: Free T4Potential ComplicationsAtrial fibrillationCongestive heart failureOphthalmopathyStrokeSeizureOsteopenia / osteoporosisAssessment findings to support diagnosis choiceLab results confirm thyrotoxicosis and Grave’s diseaseThis is also confirmed by patient’s physical examination and vital signs, and recent symptoms R00.0: Sinus Tachycardia 84439: TSH84429: Free T384479: T3 uptake86376: Thyroid peroxidase antibodiesACTIONSNON-PHARMACOLOGICThyroidectomyPt. advised if this action was taken, she may become hypothyroid and may need to be on long-term levothyroxine.PHARMACOLOGICRadioactive iodine. Pt. advised if this action was taken, she may become hypothyroid and may need long term levothyroxine. Taking into account the patient’s preference and values after a detailed discussion of treatment; Antithyroid medication example methimazole 10mg po bid was prescribed to patient to reduce thyroxine levels to a clinical euthyroid state. Evidence shows that patients may go into full remission after taking this medication. TESTING/PROCEDURES Repeat TSH, Free T3, T4, TSIPREVENTATIVE/ EDUCATIONImportance of not getting pregnant while on medication due to the risk of teratogenicity and fetal hypothyroidism.Reducing Iodine intake in dietMonitor for: possible infections like fever, sore throat, common cold since antithyroid medication can cause leukopenia Bleeding like bruising, blood in stools since methimazole can cause agranulocytsis, thrombocytopenia, aplastic anemia Liver damage that may manifest as yellow discoloration of the skin and eyes since medications can cause hepatotoxicityFOLLOW UPFollow up in 6 weeks. Repeat labs as aboveREFERENCESUnited States Department of Health and Human Services. (2017). Graves' disease. Retrieved from: . Domino, F.J., Baldor, R. A., Golding, J. & Stephens, M. B. (2019). The 5- minutes clinical consult premium 2019.?27th edition. Philadelphia: Wolters Kluwer.27: 762-763 CLINICAL REFLECTION As I reflect on the management of this patient, I will not change the treatment plan, I think that by repeating the laboratory values and having the patient return for a follow up visit, was a great way to confirm that the patient did in fact have low TSH levels and high Free T4 and T 3 level which were consistent with a diagnosis of thyrotoxicosis, along with the patient’s present symptoms and vital signs. Also making the patient return for review and educating her about her treatment options was essential, since it would allow the patient to make an informed decision about her care. The practitioner knew his limitations, by knowing exactly when to referral the patient to the endocrinologist. The practitioner used evidenced based practice because of the type of lab test that were ordered to confirm the diagnosis of thyrotoxicosis. The practitioner was effective in educating the patient and providing adequate preventative measures to stay healthy and cope with symptoms of her illness by counselling her about adverse effects of medications.As an FNP student, I appreciated assisting in taking care of this patient and was able to address learning outcomes. - Analyze assessment findings to design, implement, and evaluate a holistic, comprehensive plan of care for the client with acute and episodic health condition One weakness that I identified was a lack of adequate preparation and revision for the examination. I felt like this when I met the patient for the first time. Although I was able to identify her condition due to her presenting symptoms, I needed more preparation in understanding the management and treatment of her condition especially with understanding her laboratory findings. Thanks to my FNP and adequate reading, I was able to understand the lab values in patients with Thyroid disorders - TSH is usually low, while Free T and, FreeT4 are high in patients with thyrotoxicosis. I was very grateful to come into contact with this patient and really understand the management of Graves disease. ................
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