Health Assessment SOAP NOTE.

Posted: November 10th, 2022

Health Assessment SOAP NOTE.

WEEK5 ASSIGNMENT 1- SOAP NOTE: Focused Thyroid Exam (WK5Assgn1+last name+first initial) In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions. To Prepare • By Day 1 of this week, you will be assigned to a specific case study for this Case Study Assignment. Health Assessment SOAP NOTE.

ORDER A PLAGIARISM-FREE PAPER HERE

Please see the “Course Announcements” section of the classroom for your assignment from your Instructor. • Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case. With regard to the case study you were assigned: • Review this week’s Learning Resources and consider the insights they provide. • 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?Health Assessment SOAP NOTE. • Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. 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. By Day 6 of Week 5 Submit your Assignment. Submission and Grading Information To submit your completed Assignment for review and grading, do the following: • Please save your Assignment using the naming convention “WK5Assgn1+last name+first initial.Health Assessment SOAP NOTE.(extension)” as the name. 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 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. RESOURCESHealth Assessment SOAP NOTE. ________________________________________ Learning Resources Required Readings (click to expand/reduce) Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. • Chapter 11, “Head and Neck” This chapter reviews the anatomy and physiology of the head and neck. The authors also describe the procedures for conducting a physical examination of the head and neck. • Chapter 12, “Eyes” In this chapter, the authors describe the anatomy and function of the eyes. In addition, the authors explain the steps involved in conducting a physical examination of the eyes. • Chapter 13, “Ears, Nose, and Throat” The authors of this chapter detail the proper procedures for conducting a physical exam of the ears, nose, and throat. The chapter also provides pictures and descriptions of common abnormalities in the ears, nose, and throat. Health Assessment SOAP NOTE., J. E., Baumann, L. C., & Scheibel, P. (2019). Advanced health assessment and clinical diagnosis in primary care (6th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Advanced Health Assessment and Clinical Diagnosis in Primary Care, 6th Edition by Dains, J.E., Baumann, L. C., & Scheibel, P. Copyright 2019 by Mosby. Reprinted by permission of Mosby via the Copyright Clearance Center. Chapter 15, “Earache” This chapter covers the main questions that need to be asked about the patient’s condition prior to the physical examination as well as how these questions lead to a focused physical examination. Chapter 21, “Hoarseness” This chapter focuses on the most common causes of hoarseness. It provides strategies for evaluating the patient, both through questions and through physical exams. Chapter 25, “Nasal Symptoms and Sinus Congestion” In this chapter, the authors highlight the key questions to ask about the patients symptoms, the key parts of the physical examination, and potential laboratory work that might be needed to provide an accurate diagnosis of nasal and sinus conditions. Chapter 30, “Red Eye” Health Assessment SOAP NOTE. The focus of this chapter is on how to determine the cause of red eyes in a patient, including key symptoms to consider and possible diagnoses. Chapter 32, “Sore Throat” A sore throat is one most common concerns patients describe. This chapter includes questions to ask when taking the patient’s history, things to look for while conducting the physical exam, and possible causes for the sore throat. Chapter 38, “Vision Loss” This chapter highlights the causes of vision loss and how the causes of the condition can be diagnosed. Note: Download the six documents (Student Checklists and Key Points) below, and use them as you practice conducting assessments of the head, neck, eyes, ears, nose, and throat. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., & Solomon, B. S., & Stewart, R. W. (2019). Head and neck: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Eyes: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Student checklist. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Health Assessment SOAP NOTE.Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Ears, nose, and throat: Key points. In Seidel’s guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby. Credit Line: Seidel’s Guide to Physical Examination, 9th Edition by Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2019 by Elsevier Health Sciences. Reprinted by permission of Elsevier Health Sciences via the Copyright Clearance Center. Colyar, M. R. (2015). Advanced practice nursing procedures. Philadelphia, PA: F. A. Davis. Credit Line: Advanced practice nursing procedures, 1st Edition by Colyar, M. R. Copyright 2015 by F. A. Davis Company. Reprinted by permission of F. A. Davis Company via the Copyright Clearance Center. • Chapter 71, “Visual Function Evaluation: Snellen, Illiterate E, Pictorial This section explains the procedural knowledge needed to perform eyes, ears, nose, and mouth procedures. Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis. • Chapter 2, “The Comprehensive History and Physical Exam” (Previously read in Weeks 1, 3, 4, and 5) Bedell, H. E., & Stevenson, S. B. (2013). Eye movement testing in clinical examination. Vision Research 90, 32–37. doi:10.1016/j.visres.2013.02.001. Health Assessment SOAP NOTE.Retrieved from https://www.sciencedirect.com/science/article/pii/S0042698913000217 Rubin, G. S. (2013). Measuring reading performance. Vision Research, 90, 43–51. doi:10.1016/j.visres.2013.02.015. Retrieved from http://www.sciencedirect.com/science/article/pii/S0042698913000436 Harmes, K. M., Blackwood, R. A., Burrows, H. L., Cooke, J. M., Harrison, R. V., & Passamani, P. P. (2013). Otitis media: Diagnosis and treatment. American Family Physicians, 88(7), 435–440. Retrieved from http://www.aafp.org/journals/afp.html Note: You will access this article from the Walden Library databases. Otolaryngology Houston. (2014). Imaging of maxillary sinusitis (X-ray, CT, and MRI). Retrieved from http://www.ghorayeb.com/ImagingMaxillarySinusitis.html This website provides medical images of sinusitis, including X-rays, CT scans, and MRIs (magnetic resonance imaging). Document: Episodic/Focused SOAP Note Exemplar (Word document) Document: Episodic/Focused SOAP Note Template (Word document)Health Assessment SOAP NOTE.

Subjective Data

Chief Complaint: “I feel extremely tired and my hair is falling out”

HPI: The patient is a middle-aged woman who presented with complaints of feeling extremely tired and hair falling out. These symptoms were associated with marked increase in weight (30 pounds) in the past one year and a reduced appetite. Hair thinning, fatigue, weight gain, and reduced appetite are some of the major symptoms of hypothyroidism, a thyroid disorder that is common among women and whose symptoms tend to gradually develop over time (Dunn & Turner, 2016). Therefore, additional data on the exact onset of these symptoms should be obtained as well as potential relieving and accelerating factors. It should also be ascertained if the patient had associated symptoms of a puffy face, an impaired memory, tenderness and stiffness of the muscles which are significant for thyroid disorders.Health Assessment SOAP NOTE.

Current Medications: ask the patient if she is currently taking any medications. There are certain medications, especially those used in the management of psychiatric disorders such as lithium which has a direct effect on the thyroid gland by lowering the production of thyroid hormone.Health Assessment SOAP NOTE.

Past Medical History: A past history of thyroidectomy, radiation to the upper chest or neck, treatment with anti-thyroid medications or radioactive iodine and an underlying autoimmune disease will be relevant since these are potential risk factors of hypothyroidism.Health Assessment SOAP NOTE.

Family History: Thyroid disorders such as hyperthyroidism, hypothyroidism among others have a familial tendency. Therefore, ascertaining if the patient has a positive familial history of thyroid disease will be necessary.Health Assessment SOAP NOTE.

Review of Systems

General Exam: patient appears extremely tired with fallen out hair. She has gained 30 pounds in the past year.

HEENT: Ask about changes in hearing and vision, ringing and discharge in the ears, hoarseness of the voice, an enlarged thyroid gland.

Skin: feels cold all the time. Ask about the dryness of the skin, nails, sweating. Reduced energy slows down metabolism which decreases sweating (Dunn & Turner, 2016). As a result, the skin may become flaky and dry and the nails become brittle.

Cardiovascular: ask about palpitations, chest pains, central and peripheral cyanosis since low levels of thyroid hormone increase the risk of heart failure.Health Assessment SOAP NOTE.

Respiratory: ask about recurrent respiratory tract infections, shortness of breath and cough

Gastrointestinal: patient reports a reduced appetite and marked weight gain. Ask about constipation. Reduced energy which slows metabolism slows down the digestive process which leads to constipation.

Genitourinary: ask about recurrent or recent urinary tract infections and urinary symptoms of urgency, burning on urination and changes in the color of urineHealth Assessment SOAP NOTE.

Gynecological: ask about contraception, menstrual flow, deliveries and STDs

Neurological: ask about dizziness or syncope, tremors, and abnormalities in gait, changes in speech and movement. Low levels of thyroid hormone slow down the pumping of blood to vital organs and tissues such as the brain and this may influence problems in balance (Dunn & Turner, 2016).

Musculoskeletal: Ask about any muscle or joint pains, stiffness, and swellings. Hypothyroidism can contribute to stiffness, swelling and pain of small and big joints of the feet and hands and ultimately carpal tunnel syndrome.Health Assessment SOAP NOTE.

Psychiatric: the patient had difficulties sleeping, maintained interest in her hobbies. Ask about difficulty concentrating, problems in memory and anxiety. Hypothyroidism shares similar symptoms with depression thus only a proper diagnosis will ensure proper treatment.

Endocrine: the patient feels cold all the time. Ask about bruising, sweating, and swollen lymph nodes and palpable masses.Health Assessment SOAP NOTE.

Objective Data

Physical Exam

Record Chantal’s: Weight, Height, BMI, Temperature, Pulse, Blood Pressure and Respiratory rate. Thyroid disorders manifest with obesity as revealed by the BMI since more calories are stored in the form of fat, a slow heart rate, a high blood pressure, and slow respiratory rate.

General Appearance: Observe overall grooming and appearance, alertness and orientation.Health Assessment SOAP NOTE.

HEENT: fallen out hair. Assess for hair distribution, sclera and conjunctivae injection, patency of ear canals, the color of bilateral tympanic membranes, the color of the nasal mucosa, range of movement of the neck, lymphadenopathy, thyromegaly, the color of the oral mucosa and pharynx.Health Assessment SOAP NOTE.

Skin: skin is cold and clammy. Assess for dryness, bruises, lesions, the nails, and hair distribution

Gastrointestinal: Assess for abdominal tenderness, scars, hepatosplenomegaly and bowel sounds.

Cardiovascular: assess for heart rate and rhythm, additional heart sounds, murmurs and rubs, capillary refill, edema, and pulses.

Psychiatric: Patient is Alert and Oientedx3. Assess for overall grooming and hygiene, speech, mood, affect and response to questions.

Musculoskeletal-assess for the range of movement of all joints, joint swellings, and stiffness

Respiratory-assess respiration effort, breath sounds, lung fields

Diagnostic Tests

TSH and T4 tests- measures the amount of TSH (thyroid-stimulating hormone) created by the pituitary gland). High TSH levels will indicate hypothyroidism and vice versa. The test will help to evaluate the functioning of the thyroid gland and to diagnose hypothyroidism (Dunn & Turner, 2016).

Complete Blood Count- most thyroid disorders are accompanied by abnormalities of red blood cells since thyroid hormone directly affects erythropoiesis. A CBC will also help to check on an individual’s overall health and any underlying infections.

Comprehensive metabolic panel- measures blood glucose, the balance of fluids and electrolytes, liver and kidney function. The overall results reveal the body’s metabolism and can be used to differentiate metabolic disorders with similar presentation to thyroid disorders.

Lipid Panel- thyroid hormones have a vital role in the metabolism of lipids. An increased lipid profile will suggest hypothyroidism.Health Assessment SOAP NOTE.

Assessment

Differential Diagnoses

Hypothyroidism unspecified- Chantal is a middle-aged woman whose symptoms of cold intolerance, extreme tiredness, falling out of hair, reduced appetite and marked weight gain (30pounds in the last year) are consistent with hypothyroidism. The female gender is a risk factor of hypothyroidism. Fatigue usually occurs as a result of low functioning of the thyroid which leads to reduced energy. Therefore, the body generates less heat which contributes to cold intolerance. With reduced energy needs, the body requires fewer calories and this contributes to a reduced appetite. Since only a few calories are converted to energy, the remainder is stored as fat hence the gradual weight gain (Sanyal & Raychaudhuri, 2016).Health Assessment SOAP NOTE.

Subclinical iodine-deficiency hypothyroidism occurs as a result of a deficiency in iodine and has similar signs and symptoms as clinical hypothyroidism. Iodine deficiency can only be confirmed through a laboratory test (Zimmermann & Boelaert, 2015). However, since the patient reported no history of iodine deficiency, it is a less likely diagnosis.Health Assessment SOAP NOTE.

Chronic fatigue– patients with chronic fatigue experience diffuse muscle and joint pains, sleep disturbance, have difficulty performing ADL, social and educational activities alongside minor changes in endocrine functioning for more than 6 months (Naviaux et al., 2016).  However, the patient in this case still enjoyed her hobbies and had the additional symptom of hair falling out and marked weight gain which makes it a less likely diagnosis.Health Assessment SOAP NOTE.

Depression: patients with depression have a similar clinical presentation as those with thyroid disorders.  This includes difficulties sleeping, weight gain, extreme fatigue, loss of interest in social, educational, and occupational activities. Ruling out this diagnosis would require the administration of a questionnaire that assesses for depression.

Unspecified Anemia: Anemia causes fatigue, insomnia, difficulty concentrating, and reduced appetite among other symptoms. Although these symptoms are similar to Chantal’s no pertinent history is provided as a probable cause of anemia. Thus, it’s a less likely diagnosis.Health Assessment SOAP NOTE.