­­­­SOAP Note Discussion

­­­­SOAP Note Discussion

­­­­SOAP Note Discussion

Subjective

Patient:  S.D., 67-year-old, female

Chief Complaint: “I have lost about 50 pounds”.

History of Present Illness: S.D. is a 67-year-old African American female with a past medical history of hypertension, parathyroidectomy and nephrectomy who presents to the clinic with unexplained weight loss for the past 3 months. She reports losing 50 lbs in that timeframe and states she has never lost weight like this before in the past. S.D. reports feeling very fatigued, weak and short of breath on exertion with no motivation to do anything. She reports she has been having these symptoms for the last couple of months. S.D. also states she has been having multiple episodes of diarrhea throughout the day. She is afebrile currently and denies any nausea and vomiting. S.D denies any recent travel out of the country.

Past Medical History:  HTN, kidney stones and hay fever

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Past Surgical History:

• Hysterectomy
• Oophorectomy
• Parathyroidectomy 2 years ago, unsure why she had removal.
• Nephrectomy 3 years ago, unsure why she had removal.

Medications:

• Indapamide once daily
• Metoprolol Succinate once daily
• Isoptin once daily
• Fosinopril sodium once daily

She quit taking medications 2 months ago because she felt like they were making her sick.

Allergies: None

Immunizations: Up to date

Hospitalizations: None

Family History: 

Seven living children

Mother: Deceased, age unknown, tuberculosis

Father: Deceased, age unknown, heart attack

Social History:

S.D. is currently working at First Presbyterian Church in the nursery and volunteers with the kindergarten class which she has been there for 16 years. S.D. currently lives with her husband who she has been married to for 43 years near the downtown area. She is a vegetarian and states her diet is healthy. S.D. does not exercise regularly due to her extreme fatigue and shortness of breath, but she does house chores/errands that keep her busy and moving. She denies any use of alcohol, tobacco, and illicit drugs.

General: Positive for weight gain changes. Negative appetite changes, fever, chills.

Head: Positive dizziness. Negative for sinus pain/pressure.

Eyes: Negative for visual changes, blurred vision or floaters in eye. Negative double vision, eye redness, eye drainage.

Ears: Negative for changes or difficulty in hearing, ear pain, or drainage.

Nose: Negative for difficulty smelling, rhinorrhea. Negative for nasal congestion and epistaxis.

Mouth/Throat: Negative for swallowing problems, difficulty eating/chewing foods, mouth sores or lesions, or sore throat.

Neck: Denies neck stiffness, pain, or reflux.

Respiratory: Negative for cough, sputum, or wheezing. Positive for shortness of breath and dyspnea on exertion.

Cardiovascular: Negative for chest pain. Positive for irregular fast heartbeat and palpitations. Positive ankle swelling.

GI: Negative for nausea/vomiting, heartburn, acid reflux, abdominal pain, pain with defecation, hemorrhoids, rectal bleeding, constipation. Positive diarrhea.

GU: Negative for urinary difficulties, painful urination, frequency, or urgency.

Musculoskeletal: Negative for joint pain or stiffness, problems with a range of motion, or backache.

Neurological: Positive for muscle weakness and dizziness. Negative unsteady gait, memory changes, or mood changes.

Psychiatric: Positive for anxiety. Negative for sleep disturbances.

Skin: Negative for skin color changes, Positive hair loss.

Endocrine: Positive for weight loss. Positive for heat intolerance. Negative for excessive thirst, or hunger. Positive for fatigue and tired.

Hem/Lymph: Negative for bruising, excessive healing time.

Objective

PHYSICAL EXAM

Vital Signs: 

Temp 97.1 ^o, BP 155/76, Pulse 96, Respiratory Rate 16, O2 97 %, Height 5’2 (157.5cm), Weight 136 lbs (61.7 kg) BMI 25

Rhythm: Normal Sinus Rhythm Arrhythmia

Orthostatic vital signs

Arm: Standing- 150/72 Supine- 155/78

General: S.D. is a 67 y/o African female. She is alert and oriented and answers questions appropriately. Patient is cooperative and anxious about what could possibly be going on with her health. She follows commands appropriately. Appears hydrated and well-nourished. Affect is good.

Neurological: Alert and cooperative. A&O x 4.

HEENT:

Head: The skull is normocephalic, no trauma, no deformities noted. Hair with normal distribution.

Eyes: Pupils equal, round, and reactive to light bilaterally. No nystagmus, no lesions noted. Conjunctiva moist without discharge.

Ears: Tympanic membranes pearly grey and intact with good cone of light.

Nose: Nasal mucosa pink and moist. Nasal passages are clear.

Throat/Mouth: Pink moist oral mucosa.

Neck: Trachea midline. Visible thyroid fullness and diffuse enlargement on palpation.

Lymph Nodes: No palpable nodes.

Respiratory: Lungs clear to auscultation.

Cardiovascular: S1 and S2 heart sounds present. No murmurs noted.

GI: Abdomen flat, nondistended and no tenderness. The gallbladder is not palpable. The liver edge is palpable on deep inspiration. Abdominal clicks and gurgles her on auscultation with occasional borborygmi.

Skin: No lesions, rashes or other skin changes.

Psychiatric: Patient appears anxious about what could be going on with her health.

 

Diagnostic tests

CBC w/diff

WBC                           5,100/mm³

RBC                            4.82 m/mm³

Hemoglobin                11.2 g/dL

Hematocrit                  35.7%

MCV                           74.1 fL

MCH                           23.3 pg

MCHC                        31.5%

Platelets                       307,000/mm³

Bands                          0.5% WBC count

Neutrophils                 56% WBC count

Lymphocytes              26% WBC count

Eosinophils                  6% WBC count

Monocytes                  11.1% WBC count

Basophils                     0.4% WBC count

 

Urinalysis

specific gravity	1.020
pH	5.5
protein	negative
bilirubin	negative
glucose	negative
ketones	negative
occult blood	negative
RBCs/HPF	0/hpf
WBCs/HPF	0/hpf
bacteria	negative
casts	0 hyaline casts/lpf
crystals	0
Nitrates	negative
Urobilinogen	negative

CMP

Glucose           120 mg/dL

BUN                10 mg/dL

Creatinine        0.7 mg/dL

Sodium            146 mEq/L

Potassium        4.2 mEq/L

Chloride          106 mmol/L

CO2 27            mEq/L

Calcium           9.2 mg/dL

AST                 36 U/L

ALT                30 U/L

T4                    22.8 mcg /dL

T3                    350 ng//dL

TSH                 0.4 mU/L

Ultrasound of Thyroid Gland- No masses or cysts visible. Thyroid measures about twice the normal size.

TRH Stimulation test- Consistent with hyperthyroidism.

Thyroid uptake and scan- high.

Echo- Mild concentric LVH.

Chest X-ray- Adenopathy in anterior mediastinum, right paratracheal region, and right hilum. Also there is a < 1 cm parenchymal nodule in the left lung base. There is pleural thickening posteriorly and inferiorly on the right.

Assessment

Differential diagnosis

1. Hyperthyroidism (Thyrotoxicosis)- Hyperthyroidism (Thyrotoxicosis) affects multiple systems and is characterized by systemic clinical manifestations. The disease symptoms are caused by increased sensitivity to adrenergic hormones. They include palpitations, nervousness, hyperactivity, increased perspiration, heat hypersensitivity, weight loss despite increased appetite, fatigue, weakness, insomnia, and frequent bowel movements (Doubleday & Sippel, 2020). Physical findings include warm moist skin, tachycardia, tremor, widened pulse pressure, and atrial fibrillation. In addition, hyperthyroidism is associated with eye signs like eyelid lag, eyelid retraction, stare, and mild conjunctival injection caused by excessive adrenergic stimulation. Hyperthyroidism was a differential diagnosis due to the patient having pertinent positives of weight loss greater than 50 lbs in 3 months, fatigue, weakness, nervousness/anxiety, and frequent bowel movements. She also had a past history of parathyroidectomy which puts her at risks for having hormonal imbalances in the future.
2. Depression- The primary clinical manifestations of depression are a feeling of sadness or depressed mood and a loss of interest or pleasure in previously enjoyable activities. Other manifestations include appetite changes, sleeping difficulties, increased fatigue, reduced energy levels, slowed movements/speech, feelings of inappropriate guilt, concentration difficulties, and suicidal ideations/thoughts (Christensen et al., 2020). Depression was a differential diagnosis due to the pertinent positives of weight loss of 50 lbs in 3 months, increase in fatigue/tiredness, low levels of energy and decreased motivation to get up and do things. I ruled this differential out since patient has no history of psychiatric issues and denies any currently.
3. Malignancy- The clinical manifestations and physical findings of malignancy are specific to the organ or system where the tumor has grown. Individuals with malignancy report general symptoms like weight gain or weight loss with no known reason, severe and prolonged fatigue, and fever or night sweats for no known reason (Koo et al., 2020). Malignancy in the GI system can cause pain after eating, constant heartburn or indigestion, trouble swallowing, abdominal pain, nausea, vomiting, and appetite changes. Physical findings in malignancy include swelling or lumps in areas such as the neck, stomach, axillae, and groin. Malignancy was included in the differentials since the patient had pertinent findings of weight loss of 50 lbs that was unexplained and not due to increases physical activity such as exercise. She also had increased fatigue and wasn’t able to do a lot of daily living activities due to the fatigue. I ruled this differential out because patient had no palpable masses on exam. Patient was also negative for any night sweats.

4. Infection- The clinical manifestations of infection are mostly based on the affected organ or body system. General symptoms include fever, chills, sweats, general body malaise, headache, new or sudden exacerbation of pain, skin flushing, unexplained fatigue, and swollen lymph nodes. Local physical exam findings include erythema, soreness, swelling, tenderness on palpation, warmth, and loss of function in the affected part. The WBC count is usually elevated. Infection was a differential diagnosis due to the pertinent findings of general fatigue/tiredness and GI symptoms could been an infection. This diagnosis was ruled out due to patient WBC was WNL and she had no tender/swollen lymph nodes on exam.

Working diagnosis

Hyperthyroidism (Thyrotoxicosis) secondary to parathyroidectomy E21.1

Problem list

1. Hyperthyroidism (Thyrotoxicosis) secondary to parathyroidectomy 1
2. Goiter  9
3. Hypertension I10
4. Mild concentric left ventricular hypertrophy              2

Plan

-Referral to endocrinology for management long-term.

-Start Methimazole 15mg per day, titrate up if needed (Epocrates, 2022).

-Start Propranolol Hydrochloride 10mg orally four times daily, gradually increase until symptoms and pulse are controlled, then gradually taper when euthyroid (Epocrates, 2022).

-Recheck T3, T4, and TSH labs after starting Methimazole in 4 weeks until euthyroid, then every 3 months while on Methimazole (Hollier, 2021).

-Goal is to attain euthyroid state within 3-8 weeks (Hollier, 2021).

-Monitor CBC and LFTs.

-Restart home medications, patient stopped taking:

• Indapamide once daily
• Isoptin once daily
• Fosinopril sodium once daily
• Stop Metoprolol succinateà propranolol started

-Referral to cardiologyà monitor annual echo, monitor EKG, management of BP medications

-Follow with PCP every 6 months for medical management and to follow

References

Christensen, M. C., Wong, C., & Baune, B. T. (2020). Symptoms of Major Depressive Disorder

and Their Impact on Psychosocial Functioning in the Different Phases of the Disease: Do

the Perspectives of Patients and Healthcare Providers Differ?. Frontiers in psychiatry, 11,

280. https://doi.org/10.3389/fpsyt.2020.00280

Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland surgery, 9(1), 124–135.

https://doi.org/10.21037/gs.2019.11.01

Epocrates. (2022). Drug lookup. https://online.epocrates.com

Hollier, A. (2021). Clinical guidelines in primary care (4th ed.). Advanced Practice Education

Associates.

Koo, M. M., Swann, R., McPhail, S., Abel, G. A., Elliss-Brookes, L., Rubin, G. P., &

Lyratzopoulos, G. (2020). Presenting symptoms of cancer and stage at diagnosis:

evidence from a cross-sectional, population-based study. The Lancet. Oncology, 21(1),

73–79. https://doi.org/10.1016/S1470-2045(19)30595-9

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­­­­SOAP Note Discussion

Symptomatic primary hyperparathyroidism may lead to an indication of parathyroidectomy. Patients who present with polydipsia and polyuria, nephrolithiasis or nephrocalcinosis, hypercalciuria (24-hour urine calcium level >400 mg/dL), impaired renal function (GFR <60 mL/minute), osteoporosis (BMD score <-2.5), fragility fracture or vertebral compression fracture, peptic ulcer disease or gastroesophageal reflux, pancreatitis,  and neurocognitive dysfunction or neuropsychiatric symptoms due to hyperparathyroidism may require parathyroidectomy (Majcen & Hocevar, 2020). Parathyroidectomy is also indicated in asymptomatic patients with endocrine disorders based on the following circumstances: Age below 50 years; Serum calcium level >1 mg/dL above the normal range; Urinary calcium excretion > 400 mg per 24 hours; Creatinine clearance that has reduced by more than 30% compared with age-matched persons; Bone density > 2.5 standard deviations below peak bone mass.

Primary hyperparathyroidism is linked with an increased risk of renal stones. Hypercalciuria is a primary finding in primary hyperparathyroidism and has been associated with the formation of renal stones. Elevated levels of parathyroid hormone (PTH) act directly on the kidney, resulting in increased kidney reabsorption of calcium and increased phosphate excretion (Almquist et al., 2020). The processes cause excessive calcium (hypercalcemia) and low phosphate levels (hypophosphatemia) in patients with hyperparathyroidism. Thus, the patient’s history of hyperparathyroidism could be the cause of renal calculi.

The parathyroid glands maintain calcium and phosphate balance. It maintains serum calcium levels within a narrow range, but phosphate levels vary more widely. The parathyroid glands secrete PTH, which acts on receptors in the kidney, bone, and intestines (Almquist et al., 2020). As a result, calcium levels are increased in the extracellular fluid, including in the blood, plasma, and interstitial fluid. A feedback inhibition mechanism occurs, which reduces the secretion of PTH.

References

Almquist, M., Isaksson, E., & Clyne, N. (2020). The treatment of renal hyperparathyroidism. Endocrine-related cancer, 27(1), R21-R34. https://doi.org/10.1530/ERC-19-0284

Majcen, M., & Hocevar, M. (2020). Surgical options in treating patients with primary hyperparathyroidism. Radiology and oncology, 54(1), 22–32. https://doi.org/10.2478/raon-2020-0010