Soap Note 1 “ADULT”  Hypothyroidism Follow the Soap Note: Use APA format and must include mia minimum of 2 Scholarly Citations. Must use the sample templates for your soap note. Keep this template for when you start clinicals. The use of templates is ok with regards to Turn it in, but the Patient History, CC, HPI, Assessment, and Plan should be of your own work and individualized to your made-up patient. please use the template

SOAP Note 1: Hypothyroidism in Adults

Subjective:
The patient, a 45-year-old female named Mrs. Smith, presents with complaints of fatigue, weight gain, constipation, and dry skin. She reports feeling colder than usual, experiencing low mood, and having difficulty concentrating. Mrs. Smith mentions that her symptoms began gradually over the past few months and have significantly impacted her daily functioning. She denies any previous diagnoses of thyroid disorder but reports a family history of hypothyroidism.

Objective:
Physical examination reveals dry skin and brittle hair, along with puffiness and dryness around Mrs. Smith’s eyes. Her blood pressure is within normal limits, and her heart rate is slightly decreased at 58 beats per minute. The patient’s body mass index (BMI) indicates she is overweight at 30.8 kg/m2. Neurological examination does not reveal any abnormalities.

Assessment:
Based on the patient’s clinical presentation and physical examination findings, Mrs. Smith is suspected to have hypothyroidism. This endocrine disorder results from inadequate thyroid hormone production, leading to a slowing down of the body’s metabolic processes. Common symptoms include fatigue, weight gain, constipation, dry skin, and signs of impaired cognition. The presence of a family history of hypothyroidism further supports this diagnosis.

Plan:
1. Further Testing: Due to the high suspicion of hypothyroidism, Mrs. Smith should undergo laboratory tests to confirm the diagnosis. This should include measurement of serum thyroid-stimulating hormone (TSH) and free thyroxine (T4) levels. Additional assessment to rule out other possible causes of her symptoms, such as anemia or depression, may also be considered.
– TSH: Elevated levels (>4.5 mIU/L) indicate primary hypothyroidism.
– Free T4: Decreased levels (<0.8 ng/dL) support the diagnosis of hypothyroidism. 2. Treatment: If the diagnosis of hypothyroidism is confirmed, appropriate treatment should be initiated. This typically involves oral administration of levothyroxine, a synthetic form of thyroid hormone. The dosage should be individualized based on the patient's specific needs, taking into account factors such as age, weight, and any underlying medical conditions. Levothyroxine is usually taken once daily, ideally in the morning on an empty stomach, to optimize absorption. Mrs. Smith should be educated on the importance of adherence to treatment and the need for regular follow-up to monitor thyroid function. 3. Lifestyle modifications: In addition to medication, lifestyle modifications can help manage Mrs. Smith's symptoms and contribute to her overall well-being. She should be encouraged to engage in regular physical activity, such as brisk walking or swimming, for at least 150 minutes per week. This can aid in weight management, improve cardiovascular health, and increase energy levels. A balanced and nutritious diet, consisting of whole grains, lean proteins, fruits, and vegetables, should be recommended to support optimal thyroid function. Mrs. Smith should also be advised to limit her intake of processed foods and sugary beverages, as these can negatively affect metabolic function. 4. Education: Mrs. Smith should be educated about the chronic nature of hypothyroidism and the need for lifelong management. She should be informed that symptoms may take several weeks to improve after initiating levothyroxine treatment. Additionally, regular follow-up appointments will be necessary to monitor her thyroid hormone levels and adjust medication dosage if needed. Patients with hypothyroidism should be counseled on the potential for long-term complications, such as cardiovascular disease and osteoporosis, and the importance of preventive measures, such as regular exercise and calcium and vitamin D supplementation when indicated. References: 1. Ross DS. Diagnosis of hypothyroidism. Uptodate. 2020. https://www.uptodate.com/contents/diagnosis-of-hypothyroidism. Accessed March 1, 2021. 2. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012;22(12):1200-1235. doi:10.1089/thy.2012.0205.