SOAP Note for Endocrine

SOAP Note for Endocrine

Student Name

Institutional Affiliation

Course

Instructor

Due Date

Patient Information: 

Name: Jane Tom 

Age: 45 

Gender: Female 

Date: September 23, 2024 

Occupation: Teacher 

MRN: 863459 

Subjective: 

CC: "I feel tired all the time and I have gained weight without changing my diet."

HPI:

Jane is a 45-year-old woman who expresses constant feeling of tiredness and gaining weight despite no changes in her diet. Her fatigue is persistent, with a significant 15-pound weight gain over six months and heightened sensitivity to cold temperatures. She describes herself as feeling "sluggish," struggling to focus at work due to her constant exhaustion. Jane also notes experiencing more infrequent bowel movements, occurring every three to four days instead of daily, and facing challenges like hair thinning around her hairline and rough skin texture. Her sleep patterns have also been disrupted; she finds it hard to fall asleep and often wakes up multiple times during the night, which exacerbates her exhaustion. She has also noticed physical changes, including hair thinning, particularly around her hairline, and her skin has become dry and rough.

Furthermore, Jane mentions that her menstrual cycles have become heavier and irregular, lasting longer than usual every 35-40 days. She has no significant history of gynecological problems and denies recent travel or lifestyle changes apart from escalating fatigue levels. Despite following her medication routine diligently, she has not had her thyroid levels checked in the last six months due to scheduling clashes with her healthcare provider.  She expresses frustration with her current health management, feeling as though her symptoms are not being adequately addressed. Additionally, she discloses an increase in caffeine consumption by having two to three cups of coffee daily to combat fatigue. Jane reports increased emotional sensitivity and mild mood swings, which she attributes to her ongoing fatigue.  Jane has also started consuming energy drinks on occasion, further increasing her caffeine intake. She shares feelings of isolation, stating that she often withdraws from social activities due to low energy levels and fear of judgment from peers regarding her weight gain and fatigue.

PMH:

• Diagnosed with hypothyroidism three years ago, currently managed by levothyroxine.
• Hypertension is under control with lisinopril.
• No previous surgeries or hospital stays.

Current medications include:

• Levothyroxine 75 mcg daily.
• Lisinopril 20 mg daily.
• Daily multivitamin intake.
• Over-the-counter iron supplement due to concerns about fatigue.
• Allergies: No known drug allergies.

Endocrine SOAP Note Samples

Family History:

Jane carries a family history involving hypothyroidism and autoimmune disorders in her mother (specifically Hashimoto's thyroiditis). Her father has hypertension and hyperlipidemia, with a history of coronary artery disease. Her sister was diagnosed with type 2 diabetes, raising concerns about metabolic health in the family. 
Social History:

• Non-smoker.
• Occasional alcohol consumption (1-2 glasses per week). Jane notes that she primarily drinks wine on weekends as a way to unwind after a busy week, though she is aware of the need to moderate her intake.
• Leads a sedentary lifestyle while focusing on parenting over personal health activities for two teenage children. Her children are involved in various extracurricular activities, which often takes precedence over her own exercise routine. She expresses a desire to be more active but struggles to find the motivation and time amidst her responsibilities.
• Jane describes her daily routine as hectic, balancing work and parenting, leaving little time for self-care. Her evenings are typically consumed with helping her children with homework and preparing for the next day, resulting in late nights with inadequate rest.

Her diet mainly consists of processed foods despite efforts to include fruits and vegetables due to time constraints affecting convenience. Though she attempts meal prepping on Sundays occasionally, the demands of a busy schedule often steer her towards convenient options throughout the week.

Frequently opts for fast but unhealthy meals like fast food or frozen dinners, contributing to weight gain concerns.

• Jane reports feeling overwhelmed with balancing work and family responsibilities, contributing to her neglect of personal health. She expresses a desire to prioritize her health but feels unsure where to start.

Review of Systems:

• General: Reports fatigue, weight gain, and cold intolerance. She mentions that even minimal physical activity leads to exhaustion, and she often requires several hours of rest after work. Jane also states that her sleep quality has deteriorated, with difficulty falling asleep and frequent awakenings during the night, contributing to her daytime fatigue.
• Endocrine: Symptoms consistent with hypothyroidism, including hair thinning and skin dryness. Jane notes that her hair has become noticeably brittle and more prone to breakage, further contributing to her distress about her appearance. She also reports feeling cold even in warm environments, which she attributes to her thyroid condition.
• Gastrointestinal: Reports increased constipation, with no diarrhea or other gastrointestinal symptoms. She describes the constipation as uncomfortable and occasionally accompanied by abdominal bloating. Jane has attempted to increase her fiber intake but feels overwhelmed by her busy schedule, making it challenging to maintain a balanced diet.
• Dermatological: Dry skin noted, along with thinning hair. Menstrual: Experiences heavier and more irregular periods.  She observes that her skin has become more sensitive, leading to irritation and occasional rashes. Additionally, Jane mentions that her menstrual cramps have intensified, causing her to miss work occasionally. She has noted significant mood swings related to her menstrual cycle, which she finds concerning.
• Psychological: Expresses feelings of anxiety about her health and future, noting concerns about her ability to manage her responsibilities effectively. She describes frequent feelings of sadness and has considered seeking help, though she has not yet done so. Jane reports that her anxiety often manifests as difficulty concentrating and irritability, impacting her relationships with family and colleagues. She acknowledges feeling isolated, as her symptoms have limited her social interactions. Jane has expressed interest in exploring therapy options but feels uncertain about how to initiate the process.

Objective:

Vital Signs:

• BP: 130/80 mmHg
• HR: 72 bpm regular
• Temp: 98.2°F
• Weight: 185 lbs
• Height: 5'5"
• BMI:30.8 (Obesity).

Physical Examination: 

General Appearance: Jane appears fatigued, with mild pallor noted in her complexion.

HEENT: 

• Skin: Dry, coarse, and slightly flaky. 
• Hair: Thinning hair observed, particularly at the temples. 
• Neck: Mildly enlarged thyroid gland (goiter present) upon palpation, without tenderness or nodules noted. 
• Cardiovascular: Heart rate is regular; no murmurs or gallops detected on auscultation.
• Respiratory: Lungs are clear to auscultation bilaterally, with no wheezing or rales present.
• Gastrointestinal: Abdomen soft and non-tender; bowel sounds present but decreased; no hepatosplenomegaly observed. 
• Musculoskeletal: No joint swelling or deformities; mild stiffness noted in the neck and shoulders.
• Neurological: Patient is alert and oriented; slight cognitive slowing during conversation observed. There is notable difficulty recalling recent events, which Jane attributes to her fatigue and stress levels.

Laboratory Tests:

Thyroid Function Tests:

• Thyroid-Stimulating Hormone (TSH) level is at 7.5 mIU/L, indicating hypothyroidism.
• Free T4 level is 0.6 ng/dL, which is considered low.

Blood Analysis:

• The Complete Blood Count (CBC) falls within normal parameters, showing no signs of anemia or infection.

Metabolic Health Check:

• A Comprehensive Metabolic Panel (CMP) reveals mostly normal findings, except for slightly elevated cholesterol levels.

Lipid Profile:

• Total Cholesterol stands at 240 mg/dL, categorized as high.
• LDL cholesterol level is at 160 mg/dL, also high.
• HDL cholesterol registers at 40 mg/dL, which is on the lower side.

Vitamin Status:

• Vitamin D Level measured as 25-hydroxyvitamin D shows a value of 20 ng/mL, signaling a deficiency.
  
  

Primary Diagnosis:

The primary concern identified is hypothyroidism due to elevated TSH and low Free T4 levels. Symptoms like fatigue, weight gain, and cold intolerance align with this diagnosis.

Secondary Issues:

Include obesity with a BMI of 30.8 categorizing the patient as obese. Furthermore, hyperlipidemia poses cardiovascular risks while vitamin D deficiency impacts overall health.

Treatment Plan:

Medication Adjustments: 

Increasing levothyroxine dosage to enhance thyroid hormone levels.

Educational Guidance: Emphasizing consistent medication intake on an empty stomach for better absorption.

Discussing the importance of monitoring for side effects as dosage increases is also critical.

Follow-Up: Scheduled thyroid function tests post-dosage adjustment in 6-8 weeks.

Lifestyle Changes:

Dietary Modifications: Recommending balanced nutrition emphasizing whole foods and reduced processed food intake. Suggesting meal planning strategies to help Jane manage her time better and ensure healthier food options are available.

Exercise Routine: Suggesting tailored physical activity sessions focusing on aerobic exercises and strength training. Encouraging Jane to incorporate simple activities, such as walking during lunch breaks or taking the stairs, to gradually increase her activity level.

Psychological Support:
Encouraging Jane to explore stress management techniques, such as mindfulness practices or journaling, to help manage anxiety and improve emotional well-being. Suggesting potential resources for mental health support if she continues to experience feelings of sadness or withdrawal.

Monitoring and Follow-Up:

Regular follow-up appointments are crucial for reassessing progress in thyroid function tests along with monitoring blood pressure and lipid profile changes post-intervention.

Additional Care:

Regular rechecks of lipid panel alongside vitamin D supplementation are advised to address deficiencies effectively.

Patient Support:

Encouragement towards joining support groups can aid in coping strategies while maintaining a symptom diary helps track progress effectively during follow-up visits.

Jane's well-being should be evaluated for possible signs of depression due to her enduring fatigue and lifestyle adjustments. If her symptoms persist or worsen, it may be prudent to suggest consulting a mental health professional. Providing her with referral information for counseling services may facilitate this process.

Exploring various stress-relief methods like mindfulness, yoga, or meditation could not only enhance Jane's overall health but also potentially alleviate some effects linked to hypothyroidism. Additionally, initiating cognitive-behavioral strategies to manage her anxiety about health could provide her with valuable coping mechanisms.

To ensure optimal care for Jane, it's crucial to coordinate efforts among her primary caregiver, nutritionist, and any other specialists involved in her healthcare. Effective communication is key to tailoring an efficient management strategy for her well-being.

Equipping Jane with informative materials about hypothyroidism, dietary recommendations, and details on local exercise initiatives or community services that promote physical fitness can further support her journey towards better health.

Follow-up date: November 4, 2024.