Focused SOAP Note For Proptosis And Fatigue Case study

Patient Information:

K.K, 44, Female, African American

S.

CC: proptosis and fatigue

HPI: K.K. is an African American woman of 44 years of age who comes to the clinic in order to get a comprehensive medical examination. Her complaints include proptosis and extreme fatigue. There is visible neck swelling, hyperlipidemia, and increased TSH levels. According to her account, she began experiencing feelings of exhaustion around three weeks ago, and the issue has become more severe during the previous two days. She describes related symptoms such as cramping in her muscles and joints, as well as weakness. Despite having less of an appetite, she has seen a considerable increase in her weight. She estimates that she has gained around 30 pounds in the last year, and she is putting a lot of effort into reducing the weight that she has acquired. Focused SOAP Note For Proptosis And Fatigue Case study

Current Medications: Bupropion-naltrexone 90mg/8mg once daily for weight loss

Allergies: Reports penicillin allergy

PMHx: immunizations are current. Received all childhood immunizations. Reports history of GERD and hyperlipidemia.

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Soc Hx: K.K. makes her income as the proprietor of a grocery store. She is divorced and lives with her three children. Her hobbies include cooking and watching telenovelas. She says that she does not use alcohol, cigarettes, or illegal substances.

Fam Hx:

Mother: deceased at age 69 of breast cancer.

Father: age 72, history of hypertension.

Sister: age 48, history of arthritis

ROS:

GENERAL:  Reports fatigue, weakness, and weight gain and. Denies fever or chills.

HEENT:  Eyes: Reports bulging eyes. Ears, Nose, Throat:  Denies ear pain, hearing loss, sinus pain, nasal congestion, rhinorrhea or sore throat.

SKIN:  Denies rash, lesions, or itching.

CARDIOVASCULAR:  Denies chest pain, irregular heartbeat, palpitations or edema.

RESPIRATORY:  Denies respiratory distress, wheezing, shortness of breath, or cough.

GASTROINTESTINAL:  Denies abdominal pain, anorexia, vomiting, nausea, constipation or diarrhea.

GENITOURINARY:  Denies incontinence, hesitancy, hematuria, or pain on urination.

NEUROLOGICAL:  Denies dizziness, headaches, numbness or tingling, paralysis, syncope, or ataxia. Denies change in bladder or bowel control.

MUSCULOSKELETAL:  Denies muscle pain, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies bruising, anemia, or bleeding.

LYMPHATICS:  Reports swelling on the neck. Denies history of splenectomy.

PSYCHIATRIC:  Denies history of depression, anxiety, or other mental illnesses.

ENDOCRINOLOGIC:  Denies polydipsia or polyuria. Denies excessive sweating or cold or heat intolerance.

ALLERGIES:  Denies history of rhinitis, eczema, hives, or asthma.

O.

Physical exam:

Vital signs: H 5’4”, W 195 lbs, RR 17, HR, 76, BP 126/76, 02 Sat 98%

HEENT: Bulging of both eyes noted. Intact ears with good reflex. Thyroid gland appears swollen. Focused SOAP Note For Proptosis And Fatigue Case study

Diagnostic results:

Hemoglobin A1C, TSH, and thyroid antibody test results pending

A.

Differential Diagnoses 

1. Graves’ disease: Graves’ disease is an autoimmune condition in which healthy tissue in the thyroid gland is attacked by the body’s immune system for reasons that are not fully understood. It is by far the most prevalent reason for hyperthyroidism, which is a disease in which the thyroid gland produces an excessive amount of the hormone thyroid hormone. Graves’ disease affects more persons who were given the feminine gender at birth than it does those who were given the male gender. Although it most often affects persons between the ages of 30 and 50, it may also strike younger people and others much farther along in life (Wiersinga, 2019). If a person has a history of thyroid illness in their family or smokes cigarettes, they have a greater chance of having Graves’ disease themselves. Graves’ illness often presents itself in a manner that is slow-moving, with symptoms not becoming apparent for many weeks or even months at a time. Anxiety, hand tremors, sensitivity to heat, loss of weight, bulging eyes, and an enlarged thyroid are some of the symptoms of an enlarged thyroid. People who have this disorder are also more likely to develop symptoms such as excessive sweating, weariness, an intolerance to heat, or high blood pressure. Graves’ disease may be treated by reducing the quantity of thyroid hormone that is produced in the body or by blocking the activity of thyroid hormone. This illness may be treated in a number of ways, the most common of which are the administration of antithyroid medication, treatment with radioactive iodine, and surgical removal of the thyroid. Graves’ disease, if left untreated, may result in a number of other health complications, such as thyroid storm, cardiovascular issues, bone loss, and complications during pregnancy. Focused SOAP Note For Proptosis And Fatigue Case study
2. Hyperthyroidism: Hyperthyroidism is the medical term for the condition that occurs when the thyroid gland produces an abnormally high level of the hormone thyroxine. A number of different diseases, such as Graves’ disease, Plummer’s disease, and thyroiditis, are among the conditions that have the potential to bring on hyperthyroidism in a patient. It is a disorder in which the body’s metabolism speeds up, which causes unexpected weight loss in addition to an irregular or rapid heartbeat. It is called hypermetabolic syndrome. Because the symptoms of hyperthyroidism can be indistinguishable from those of other medical conditions, it can be challenging for a physician to diagnose the condition. It is also possible for it to cause a wide variety of signs and symptoms, some examples of which include accidental weight loss, a quick pulse, perspiration, tremor, weariness, and increased sensitivity to heat. Persons under the age of 65 are less likely than older those to exhibit any signs or symptoms at all. This is especially true for people over the age of 65. A rapid heartbeat, an intolerance to heat, and a predisposition to fatigue easily when doing routine activities are typical manifestations of this condition (Taylor et al., 2018). There are several potential treatments available for hyperthyroidism. The use of anti-thyroid medications as well as the ingestion of radioactive iodine that is prescribed by medical professionals both have the effect of lowering the rate at which thyroid hormones are produced. Hyperthyroidism may sometimes be treated by surgical removal of all or portion of the thyroid gland. The vast majority of individuals who are diagnosed with hyperthyroidism and get treatment for it have a good outcome. On the other hand, untreated hyperthyroidism may pose a serious risk to one’s life.
3. Thyroid hormone resistance: Thyroid hormone resistance is a hereditary disorder that affects one in every 40,000 live births. This illness is defined by a decreased responsiveness of target tissues to thyroid hormone, which is caused by mutations on the thyroid hormone receptor. It is possible that this illness may not be associated with any symptoms at all, or that it will be associated with symptoms of either an underactive or overactive thyroid gland. The amount of thyroid hormone in the blood is higher than normal because the pituitary gland, which is responsible for regulating the production of hormones from the thyroid gland, is not being appropriately shut down by the thyroid hormone (Singh & Yen, 2017). The swelling of the thyroid gland could be the consequence of an abnormally high level of thyroid hormone production. Peripheral tissues may develop resistant to the effects of thyroid hormones when they are subjected to high concentrations of the hormones; yet, they can also maintain their sensitivity, which can result in symptoms associated with both an overactive or underactive thyroid. When treating individuals who have this condition, the primary focus of treatment should not be on normalizing thyroid hormone levels but rather on the individual ‘s symptoms and overall clinical presentation. The majority of patients are able to successfully combat the resistance on their own via increased thyroid hormone production, and as a result, they do not need to be treated. The treatment of individuals who come with normal TSH levels is more difficult. In such individuals, the administration of supraphysiological amounts of thyroid hormone may be necessary; if this is the case, the patient’s condition should be carefully watched (Sun et al., 2020). According to their major symptoms, individuals who exhibit hyperthyroidism symptoms should get symptomatic treatment with beta-blockers or antianxiety drugs, among other treatments. Focused SOAP Note For Proptosis And Fatigue Case study
   

References

Singh, B. K., & Yen, P. M. (2017). A clinician’s guide to understanding resistance to thyroid hormone due to receptor mutations in the TRα and TRβ isoforms. Clinical diabetes and endocrinology, 3(1), 1-11. https://doi.org/10.1186/s40842-017-0046-z

Sun, H., Cao, L., Zheng, R., Xie, S., & Liu, C. (2020). Update on resistance to thyroid hormone syndromeβ. Italian Journal of Pediatrics, 46(1). https://doi.org/10.1186/s13052-020-00929-x

Taylor, P. N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J. H., Dayan, C. M., & Okosieme, O. E. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology, 14(5), 301-316. https://doi.org/10.1038/nrendo.2018.18

Wiersinga, W. M. (2019). Graves’ disease: Can it be cured? Endocrinology and Metabolism, 34(1), 29. https://doi.org/10.3803/enm.2019.34.1.29

Rubric Detail

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Name: NURS_6512_Week_5_Assignment_1_Rubric

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Using the Episodic/Focused SOAP Template:
· Create documentation or an episodic/focused note in SOAP format about the patient in the case study to which you were assigned.

· Provide evidence from the literature to support diagnostic tests that would be appropriate for your case. 45 (45%) – 50 (50%)
The response clearly, accurately, and thoroughly follows the SOAP format to document the patient in the assigned case study. The response thoroughly and accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 39 (39%) – 44 (44%)
The response accurately follows the SOAP format to document the patient in the assigned case study. The response accurately provides detailed evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study. 33 (33%) – 38 (38%)
The response follows the SOAP format to document the patient in the assigned case study, with some vagueness and inaccuracy. The response provides evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study, with some vagueness or inaccuracy in the evidence selected. 0 (0%) – 32 (32%) Focused SOAP Note For Proptosis And Fatigue Case study
The response incompletely and inaccurately follows the SOAP format to document the patient in the assigned case study. The response provides incomplete, inaccurate, and/or missing evidence from the literature to support diagnostic tests that would be appropriate for the patient in the assigned case study.
· List five different possible conditions for the patient’s differential diagnosis, and justify why you selected each. 30 (30%) – 35 (35%)
The response lists five distinctly different and detailed possible conditions for a differential diagnosis of the patient in the assigned case study, and provides a thorough, accurate, and detailed justification for each of the five conditions selected. 24 (24%) – 29 (29%)
The response lists four or five different possible conditions for a differential diagnosis of the patient in the assigned case study and provides an accurate justification for each of the five conditions selected. 18 (18%) – 23 (23%)
The response lists three to five possible conditions for a differential diagnosis of the patient in the assigned case study, with some vagueness and/or inaccuracy in the conditions and/or justification for each. 0 (0%) – 17 (17%)
The response lists two or fewer, or is missing, possible conditions for a differential diagnosis of the patient in the assigned case study, with inaccurate or missing justification for each condition selected.
Written Expression and Formatting – Paragraph Development and Organization:
Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused–neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. 5 (5%) – 5 (5%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity. A clear and comprehensive purpose statement, introduction, and conclusion are provided that delineate all required criteria. 4 (4%) – 4 (4%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 80% of the time. Purpose, introduction, and conclusion of the assignment are stated, yet are brief and not descriptive. 3 (3%) – 3 (3%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity 60%–79% of the time. Purpose, introduction, and conclusion of the assignment are vague or off topic. 0 (0%) – 2 (2%)
Paragraphs and sentences follow writing standards for flow, continuity, and clarity < 60% of the time. No purpose statement, introduction, or conclusion were provided.
Written Expression and Formatting – English writing standards:
Correct grammar, mechanics, and proper punctuation 5 (5%) – 5 (5%)
Uses correct grammar, spelling, and punctuation with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) grammar, spelling, and punctuation errors. 3 (3%) – 3 (3%) Focused SOAP Note For Proptosis And Fatigue Case study
Contains several (3 or 4) grammar, spelling, and punctuation errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) grammar, spelling, and punctuation errors that interfere with the reader’s understanding.
Written Expression and Formatting – The paper follows correct APA format for title page, headings, font, spacing, margins, indentations, page numbers, running heads, parenthetical/in-text citations, and reference list. 5 (5%) – 5 (5%)
Uses correct APA format with no errors. 4 (4%) – 4 (4%)
Contains a few (1 or 2) APA format errors. 3 (3%) – 3 (3%)
Contains several (3 or 4) APA format errors. 0 (0%) – 2 (2%)
Contains many (≥ 5) APA format errors.

This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.

Learning Objectives

Students will:

Apply assessment skills to diagnose eye, ear, and throat conditions

Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. 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.
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:

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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?
Identify at least five possible conditions that may be considered in a differential diagnosis for the patient. Focused SOAP Note For Proptosis And Fatigue Case study

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.

Case Study 2: Focused Thyroid Exam (Student last name N-Z)

Kali, a 44 year old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight. Focused SOAP Note For Proptosis And Fatigue Case study