Soap Note 1: “ADULT” – Hypothyroidism
Patient Information:
Name: Jane Doe
Age: 45
Gender: Female
Patient History:
Jane Doe is a 45-year-old female who presents with complaints of fatigue, weight gain, dry skin, and constipation. She reports difficulty concentrating and feeling cold most of the time. Jane states that these symptoms have been present for the past 6 months and have progressively worsened. She also reports a family history of thyroid disorders.
Chief Complaint (CC):
Fatigue, weight gain, dry skin, constipation
History of Present Illness (HPI):
Jane Doe describes her fatigue as constant and debilitating. She states that she struggles to complete her daily activities and often requires naps throughout the day. Her weight has increased by 15 pounds over the past 6 months despite no changes in her diet or exercise routine. She has noticed dry, flaky skin and increased hair loss. Her bowel movements have become infrequent, occurring only once every 3-4 days. Jane also reports feeling cold all the time, even when others around her are comfortable.
Past Medical History (PMH):
Jane Doe has a history of hypertension, which is well-controlled with medication. She has no previous history of thyroid disorders or any other significant medical conditions.
Family History:
Jane reports that her mother was diagnosed with hypothyroidism in her mid-40s. She is unsure of any other thyroid disorders in her extended family.
Social History:
Jane is married and has two children. She works full-time as an accountant and reports moderate stress levels. She denies tobacco or alcohol use and exercises regularly.
Medications:
Metopropol 25mg daily for hypertension
Allergies:
No known drug allergies
Review of Systems (ROS):
General: Fatigue, weight gain
Integumentary: Dry skin
Gastrointestinal: Constipation
Endocrine: Cold intolerance
Psychiatric: Difficulty concentrating
Physical Examination (PE):
– Vital signs: Blood pressure 120/80 mmHg, heart rate 75 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F
– General appearance: Patient appears fatigued, overweight
– Skin: Dry, cool to touch, no rashes or lesions
– Head and neck: Normal thyroid gland palpation, no enlargement or nodules noted
– Cardiovascular: Regular rate and rhythm, no murmurs or extra heart sounds
– Respiratory: Clear lung sounds bilaterally
– Abdomen: Soft, non-tender, normal bowel sounds
– Neurological: No focal deficits, mental status intact
Assessment:
Hypothyroidism, based on the patient’s symptoms, family history, and physical examination findings.
Plan:
1. Order thyroid function tests (TFTs) including TSH, free T4, and possibly thyroid peroxidase antibodies (TPOAb) to confirm the diagnosis.
2. Counsel patient on the importance of medication adherence and regular follow-up visits for monitoring thyroid hormone levels.
3. Initiate levothyroxine 50mcg orally once daily upon confirmation of hypothyroidism.
4. Schedule follow-up appointment in 6 weeks to evaluate response to treatment and adjust medication dosage if necessary.
5. Educate patient about the potential long-term consequences of untreated hypothyroidism, such as cardiovascular disease and infertility.
6. Provide dietary recommendations to promote weight loss, such as reducing calorie intake and increasing physical activity.
7. Refer patient to a registered dietitian for personalized nutrition counseling.
References:
1. American Thyroid Association. (2014). Hypothyroidism. Retrieved from https://www.thyroid.org/hypothyroidism/
2. Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. doi: 10.1016/S0140-6736(17)30703-1
