NURS 6512 Episodic/ Focused SOAP note Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Case Study 2: Focused Thyroid Exam
Age: 32 years
Race: African American
CC: “I am feeling tired and my hair is falling out.”
HPI: C.M is a 32-year-old African American female patient presenting with chief complaints of feeling tired and her hair falling out. She first noticed her hair falling out from her scalp 12 weeks ago, which occurred in patches when brushing her hair. The symptom of fatigue started after hair loss, about eight weeks ago. C.M. also mentions that she has gained weight, about 30 pounds, in the past year, even though she has experienced a significant decrease in appetite. She states that fatigue occurs when performing light tasks, climbing stairs, and when walking short distances. Her hair falls out when shampooing or brushing. Fatigue is exacerbated by activity and relieved by rest, while any friction on the scalp triggers hair fall. She reports trying to use hair treatments to stop the hair fall out, but they have had no impact.
Current Medications: Vitamin C supplements, 1 tablet per day, long-term use.
Allergies: No known food or drug allergies.
PMHx: Immunization is up-to-date. Last Tetanus- 16 months ago. No history of chronic illnesses. Had an Incision & Drainage in 2012 due to Abscess on the left thigh.
Social Hx: C.M is a paralegal working in a law firm. She lives in Baltimore, Maryland, with her husband and daughter aged seven years. Her hobbies include writing articles, reading novels, and skiing. She admits taking alcohol, vodka 3-4 glasses on weekends, but denies smoking or using illicit drugs. Her physical exercise routine includes taking brisk walks for about 20 minutes when going to work and swimming on weekends. She sleeps for approximately 7 hours a day and takes three balanced meals. C.M. reports attending annual well-exams, putting on safety belts while driving, and having smoke detectors.
Family Hx: The maternal grandmother has colorectal cancer, diagnosed at the age of 57 years. The paternal grandfather had renal failure. Mother had breast cancer that was successfully treated four years. Siblings are alive and well. Her daughter has eczema.
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, SOB, 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 anemia, easy bleeding or bruising, or blood transfusion.
LYMPHATICS: No history of inflamed lymph nodes or splenectomy.
PSYCHIATRIC: Reports sleeping disturbances. Denies 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.
Vital signs: BP- 110/68, PR- 68, RR- 20, Temp-97.3 F
Ht. – 5’4, Wt. – 167 pounds
HEENT: Head: Normocephalic and atraumatic. Hair black with patches of hair loss. Coarse and straw-like hair. Eyes: Sclera is white; PERRLA. Ears: T.M.s intact. Sinuses: Non-palpable. Nose: Nasal septum well-aligned. Throat: Tonsillar glands non-inflamed.
Neck: Lymph nodes non-palpable; Trachea is midline. On palpation, the Thyroid gland is nodular.
Respiratory: Rhythmic and smooth respirations. Lungs clear on auscultation bilaterally.
Cardiovascular: Capillary refill- 2 secs. No neck vein distensions or edema. RRR and S1and S2 present. No gallop sounds of systolic murmurs.
Integumentary: Skin is dry. No hypo/hyperpigmentation, skin rashes, or lesions.
Complete Blood Count- To establish the Hemoglobin and hematocrit level, red blood cell count, and white blood cell count. Low hemoglobin, hematocrit, and red blood cell count may cause fatigue and cold intolerance (Turner, Parsi & Badireddy, 2020). The white blood cell count will establish the presence of infection.
Thyroid-stimulating hormone (TSH) Test. A TSH test will establish TSH levels. An increase in TSH is associated with Hypothyroidism, while a decrease in TSH is usually present in hyperthyroidism (Chaker, Bianco, Jonklaas & Peeters, 2017).
Hypothyroidism is an endocrine condition that results from low levels of thyroid hormone (Chaker et al., 2017). It develops when the thyroid gland is not able to produce adequate amounts of thyroid hormone. Symptoms common in Hypothyroidism include dry skin, hair loss, voice changes, fatigue, constipation, cold intolerance, muscle cramps, sleep disturbances, menstrual cycle abnormalities, weight gain, and galactorrhea (Chaker et al., 2017). Physical findings that may be present in Hypothyroidism include Enlarged thyroid gland, weight gain, slowness of speech and movements, dry skin, coarse and brittle hair, pallor and jaundice (Chaker et al., 2017). Other physical findings include dull facial expressions, bradycardia, pericardial effusion, and prolonged ankle reflex relaxation time.
Hypothyroidism is the priority diagnosis based on pertinent positive findings of weight gain, hair loss, fatigue, cold intolerance, sleeping difficulties, dry skin, and coarse straw-like hair.
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.
Anemia refers to the reduction in the proportion of the red blood cells (Turner, Parsi & Badireddy, 2020). Symptoms of Anemia include weakness, tiredness, cold intolerance, lethargy, restless legs, shortness of breath on exertion, chest pain, reduced exercise tolerance, and Pica (Turner, Parsi & Badireddy, 2020). Physical findings common in Anemia include cool skin, tachypnea, hypotension, conjunctiva pallor, glossitis, tachycardia, and a systolic murmur.
Anemia is a likely diagnosis based on a positive history of fatigue, tiredness, and cold intolerance. However, there are no findings of Anemia symptoms such as pallor, shortness of breath, systolic murmur, or tachypnea, which rules out Anemia as the priority diagnosis.
Goiter is defined as the enlargement of the thyroid gland. Non-toxic goiter is characterized by thyroid gland enlargement with no disturbance in the thyroid function (Alkabban & Patel, 2020). The enlargement may be diffuse or localized growth. The goiter can compress the upper trachea, laryngeal nerves, and esophagus (Alkabban & Patel, 2020). This results in symptoms such as dysphagia, shortness of breath, and voice hoarseness caused by mechanical compression of laryngeal nerves. Physical examination findings include central neck swelling that is either smooth or nodular, and the mass moves with swallowing (Alkabban & Patel, 2020). The goiter can deviate the trachea or extend retrosternal.
Non-toxic goiter is a likely diagnosis based on positive findings of the palpable nodular thyroid gland. However, the patient has no other findings of non-toxic goiter, making it an unlikely diagnosis.
Thyroiditis is described as an inflammation of the thyroid gland (Pyzik et al., 2015). It results in either unusually high or low levels of thyroid hormones in the blood. Hashimoto’s Thyroiditis occurs due to the immune system attacking the thyroid gland, making it inflamed and damaged (Pyzik et al., 2015). As the thyroid gland is destroyed over time, it becomes unable to produce enough thyroid hormone. Hashimoto’s Thyroiditis causes symptoms of an underactive thyroid gland such as tiredness, weight gain, and dry skin (Pyzik et al., 2015). Specific symptoms of Hashimoto thyroiditis include perceiving fullness in the throat, painless thyroid enlargement, fatigue, sore throat, and temporary neck pain (Pyzik et al., 2015). On physical exam, a firm, rubbery thyroid gland is usually palpated.
Hashimoto’s Thyroiditis is a differential diagnosis based on pertinent positive findings of fatigue, weight gain, dry skin, and a palpable nodular thyroid gland. However, the patient dies not present with specific symptoms of Hashimoto’s Thyroiditis, which makes it an unlikely diagnosis.
Addison disease is characterized by primary adrenal insufficiency. It is caused by bilateral adrenal cortex destruction resulting in decreased production of adrenocortical hormones, including aldosterone, cortisol, and androgens (Bornstein et al., 2016). Symptoms of Addison include fatigue, weight loss, generalized weakness, dizziness, anorexia, nausea, vomiting, abdominal pain, tachycardia, and postural hypotension (Bornstein et al., 2016). Diffuse hyperpigmentation of the skin and mucous membranes often occurs in sun-exposed areas as well as decreased body hair (Bornstein et al., 2016). Other physical findings include dehydration and refractory hypotension.
Pertinent positive findings of Addison disease include fatigue, decreased appetite, and hair loss. Nonetheless, the patient has weight gain, which rules our Addison as the primary diagnosis.
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 and 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.