Week 5 Assignment: Episodic/Focused SOAP Note: Assessing the Head, Eyes, Ears, Nose, and Throat
Week 5 Assignment: Episodic/Focused SOAP Note: Assessing the Head, Eyes, Ears, Nose, and Throat
Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
• you will be assigned to a specific case study for this Case Study Assignment. Please see the “Course Announcements†section of the classroom for your assignment from your Instructor.
CASE STUDY: Focused Thyroid Exam
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.
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• 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:
• 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.
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.
A Sample Of This Assignment Written By One Of Our Top-rated Writers
Episodic/Focused SOAP Note: Assessing the Head, Eyes, Ears, Nose, and Throat
Patient Information:
Initials: Kali
Age: 44 years
Sex: Female
Race: African American
S.
CC (chief complaint): “Proptosis and fatigue.”
HPI: Kali is a 44-year-old African American female who has come for her physical exam complaining of proptosis and fatigue. She states that she began having increased fatigue about five months, but she thought it was because of the fatigue from the gym since she had just subscribed to a gym. However, the fatigue has gradually increased and occurs even on her rest days. About three months ago, she noticed that her eyes appeared strange as they had started protruding. She reports that the fatigue is exacerbated by intense physical exercises and is alleviated by rest. The fatigue has affected her occupational functioning because she is always tired, which affects her productivity.
Current Medications: Simvastatin 20 mg PO once daily for hyperlipidemia.
Allergies: None.
PMHx: Positive medical history of hyperlipidemia and overweight. Hx of Appendectomy in 2013.
Last Tdap- 07/2017
Last Flu shot- 03/2022
COVID vaccination- 05/2021 & 06/2021 (Astrazeneca)
Soc Hx: Kali has a degree in Business Administration and works as a supermarket supervisor. She is married and has three children, 16, 14, and 5 years old. Her hobbies include watching basketball and listening to podcasts. She smokes tobacco 1PPD and takes vodka 3-4 glasses on weekends. She reports going to the gym 3-4 days a week, but this has become difficult due to increased fatigue. She considers her husband and mother as her support system.
Fam Hx: The maternal and paternal grandmother had HTN and Diabetes. The father has Prostate cancer. The elder brother has HTN. Children are alive and well.
ROS:
GENERAL: Positive for fatigue, low energy levels, and weight gain. Negative for fever or chills.
HEENT: Eyes: Positive for bilateral proptosis. Negative for visual loss, blurred/ double vision, or excessive tearing. Ears: Negative for hearing loss or ear pain. Nose: Denies nose bleed, sneezing, or nasal discharge. Throat: Denies sore throat or pain in swallowing.
Neck: Reports neck swelling. Denies neck stiffness or pain.
SKIN: Negative for rash, lesion, discoloration, or itching.
CARDIOVASCULAR: Negative for neck vein distension, chest pain, edema, palpitations, or dyspnea.
RESPIRATORY: Negative for SOB, cough, chest pain, or sputum.
GASTROINTESTINAL: Negative for regurgitation, anorexia, vomiting, epigastric/abdominal pain, or rectal bleeding.
GENITOURINARY: Negative for genitourinary symptoms.
NEUROLOGICAL: Negative for headache, syncope, muscle weakness, dizziness, or numbness.
MUSCULOSKELETAL: Negative for back pain, joint pain, or joint stiffness.
HEMATOLOGIC: Negative for bruising, bleeding, or history of transfusion.
LYMPHATICS: Negative for enlarged lymph nodes.
PSYCHIATRIC: Denies mood or anxiety symptoms.
ENDOCRINOLOGIC: Denies excessive sweating, polyuria, increased hunger, polydipsia, or cold or heat intolerance.
ALLERGIES: Denies history of allergic symptoms.
O.
Physical exam:
Vital signs: BP- 124/74; HR-84; RR- 20; Temp- 98.4F
Wt-192 lbs; Ht-5’5; BMI- 31.9
HEENT: Head: Symmetrical and normocephalic. Eyes: Eyes bulging bilaterally, the sclera is white, the conjunctiva is pink, retraction and lag of the lid, and PERRLA. Ears: TMs are intact and shiny. Nose: Moist mucous membranes, well-aligned septum. Throat: The tongue is pink and midline; Tonsillar glands are patent.
NECK: Swollen; On palpation, the thyroid gland is smooth but have bruits.
CARDIOVASCULAR: Regular heart rate and rhythm. S1 and S2 present with no systolic murmur S gallop.
RESPIRATORY: Smooth respirations; The chest rises and falls uniformly; Lungs clear on auscultation.
Diagnostic results: Thyroid Stimulating Hormone (TSH) levels- are above the normal range.
A.
Differential Diagnoses
Grave’s Disease: The classic features of Grave’s disease include ophthalmopathy, a diffusely enlarged thyroid gland, thyroid bruits, pretibial myxedema, and elevated levels of Thyroxine. Ophthalmopathy presents with conjunctiva irritation, lid lag, lid retraction, widening of the palpebral fissures, proptosis, and defect in extraocular motion. Other common symptoms include general body weakness, fatigue, increased sweating, heat intolerance, warm, moist, fine skin, photophobia, eye pain, protruding eyes, double vision, and weight loss (Davies et al., 2020). Grave’s disease is a likely diagnosis owing to the positive symptoms of proptosis, increased fatigue, neck swelling, increased TSH levels, enlarged thyroid gland, and thyroid bruits.
Subacute Thyroiditis: This is an acute inflammatory disorder of the thyroid likely caused by a virus. Clinical features include fever, anterior neck pain, and thyroid tenderness. Patients initially present with hyperthyroidism, often followed by a transient period of hypothyroidism (Doubleday & Sippel, 2020). Positive symptoms of swollen neck and elevated TSH levels make Subacute Thyroiditis a differential diagnosis.
Hashitoxicosis: Hashitoxicosis is an autoimmune thyroid disorder that at first presents with hyperthyroidism and an increased radioiodine uptake caused by TSH-receptor antibodies. This is followed by hypothyroidism because lymphocytes infiltrate the thyroid gland (Shahbaz et al., 2018). Symptoms include the presence of a hard but painless goiter, sweating, hand tremors, increased appetite, sleeping difficulties, weight loss, fatigue, and heat intolerance. Hashitoxicosis is a differential diagnosis based on the patient’s history of fatigue and elevated TSH levels.
Exogenous hyperthyroidism: The condition develops due to excess exogenous thyroid hormone due to increased thyroid hormone intake. It is connected with low concentrations of serum thyroglobulin. Symptoms include weight loss, anxiety, palpitations, fatigue, increased frequency of bowel movements, and dyspnea (Doubleday & Sippel, 2020). Symptoms consistent with exogenous hyperthyroidism include fatigue and increased TSH levels.
Exophthalmos: Exophthalmos is characterized by protrusion of the eyeball and causes changes in the face and eyes. Ocular examination findings characteristic of hyperthyroidism but not related to infiltrative eye disease include eyelid lag, eyelid retraction, a temporal flare of the upper eyelid, and staring (Topilow et al., 2020). Exophthalmos is a differential diagnosis based on positive proptosis, lid retraction, and lid lag findings.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Davies, T. F., Andersen, S., Latif, R., Nagayama, Y., Barbesino, G., Brito, M., Eckstein, A. K., Stagnaro-Green, A., & Kahaly, G. J. (2020). Graves’ disease. Nature reviews. Disease primers, 6(1), 52. https://doi.org/10.1038/s41572-020-0184-y
Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland surgery, 9(1), 124–135. https://doi.org/10.21037/gs.2019.11.01
Shahbaz, A., Aziz, K., Umair, M., & Sachmechi, I. (2018). Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto’s Thyroiditis: A Case Report and Review of Literature. Cureus, 10(6), e2804. https://doi.org/10.7759/cureus.2804
Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal medicine review (Washington, D.C.: Online), 6(3), 10.18103/imr.v6i3.852. https://doi.org/10.18103/imr.v6i3.852
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