FNP 592 Week 7 SOAP Note Clinical Documentation Template

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Clinical Documentation Template

Student Name and clinical course: Ali Junayed (FNP 592)

ID:

Client’s Initials*: CL            Age: 20    Race: Caucasian    Gender: Female Date of Birth: January 1, 2004 Insurance: No   Marital Status: Unmarried

Subjective:

CC: 10% unexpected weight loss.

HPI: The patient reports that she has encountered an unexpected weight reduction throughout the past half year, adding up to roughly 10% of her body weight. This critical reduction in weight is disturbing, particularly considering her present state of well-being. She complains of trouble with her decreasing weight. She explains that she has not intentionally modified her eating regimen or raised her work levels to incite such changes. Close to her weight reduction, she reports sensations of weariness and intermittent, unpredictable pulses, even though she denies encountering any extra side effects or pain.

Past Medical History:

• Medical problem list: None.
• Preventative care: Up-to-date.
• Surgeries: No
• Hospitalizations: No
• LMP, pregnancy status, menopause, etc., for women: LMP was four weeks ago, regular cycle.

Allergies: NKDA 

Medications: None

Family History: Not reported.

Social History: The patient is an inhabitant of a nearby quarter as a full-time undergrad program and reports feeling some tension from homework, yet no huge, profound, or prevalent burdens. Periods are normal, and she has never had any gynecological issues or gotten pregnant.

ROS

CONSTITUTIONAL: 10% unexpected weight loss.

HEENT: No blurry vision, redness, ear pain, sinus congestion, sore throat, hearing changes, or lesions. No lymphadenopathy.

CARDIAC: Negative for chest pains or tightness.

GASTROINTESTINAL: No stomach pain or cramping with usual appetite.

GENITOURINARY: No change in frequency, color, or odor of urination.

SKIN: Denies skin rash or pain.

MUSCULOSKELETAL: No bone or joint stiffness, pain, or muscle contracture.

NEUROLOGIC: No headaches, dizziness, numbness, or tingling.

PSYCHIATRIC: No for anxiety, stress, suicidal ideations, or depression.

Objective

Vital Signs:   HR -82    , BP – 125/75      , Temp- 98 , RR-19       , SpO2- 98%           Pain- 0/10

Height- 5’4″     Weight- 145 lbs      BMI- 24.9

Labs, radiology, or other pertinent studies: TSH, T3, T4, CBC, BMP, CMP, and abdominal ultrasound.

Physical Exam

CONSTITUTIONAL: Oriented x4, alert, and denies medication or food allergies.

HEENT: Light reflex, normocephalic, atraumatic, and no infection. No discharge or tenderness. Normal mucous membranes. The throat is clear, with no erythema. The neck is symmetrical, and the trachea is midline. No enlarged nodes.

RESPIRATORY: Normal to auscultation with regular air movement. 

CARDIAC: Normal heart rate with regular S1 and S2. No murmurs.

GASTROINTESTINAL: Normal bowel sounds. Soft, non-tender abdomen with no hepatosplenomegaly.

EXTREMITIES: No swelling or peripheral edema. 

SKIN: No scars, rashes, pain, or itching.

MSK: No muscle stiffness or cramps; ROM is grossly intact and symmetrical.

ENDOCRINE: Large thyroid glands.

Assessment

Differentials:

1. 1. Hyperthyroidism: Hyperthyroidism results from an overactive thyroid gland, characterized by raised levels of T4 and T3 chemicals (Guerri et al., 2019). Normal reasons for hyperthyroidism include thyroid cancer, thyroiditis, excessive iodine intake, and Graves’ disease, all of which can prompt thyroid enlargement. Side effects related to hyperthyroidism include various indications, for example, goiter, stress, and unexplained weight loss. Left untreated, hyperthyroidism can increase the risk of heart issues and osteoporosis (Guerri et al., 2019). Treatment choices for hyperthyroidism incorporate antithyroid medications, radioactive iodine treatment, thyroid medical procedures, and beta-blockers.

• Gastrointestinal Disorder: Malabsorption and accidental weight reduction can originate from conditions like celiac disease and IBD (Shah et al., 2019). Nonetheless, the lack of gastrointestinal side effects makes this finding more uncertain in the patient’s case.
• Eating Disorder: Weight reduction is a side effect of dietary issues like anorexia and bulimia (Touyz et al., 2020). However, the patient denies consciously eating less food or encountering mental-related problems.

Plan

Diagnostics:

1. CBC
2. CMP
3. BMP
4. Ultrasound of the abdomen.
5. Thyroid function tests (National Guideline Centre (UK), 2019).

Treatment

Antithyroid and beta-blocker drugs will be prescribed to the patient based on the results of her reports. Antithyroid medications will be used to treat hyperthyroidism to lessen the thyroid hormone production by the thyroid gland. These medications work by obstructing the thyroid chemicals, especially thyroxine (T4) and triiodothyronine (T3), successfully assisting with normalizing chemical levels in the body. Normal antithyroid medications include methimazole and propylthiouracil (PTU). Beta-blockers are a class of drugs that focus on the beta-adrenergic receptors in the body. Regarding hyperthyroidism treatment, beta-blockers are frequently recommended to deal with the side effects related to increased sympathetic activity, for example, fast pulse (tachycardia), palpitations, tremors, and anxiety. 

Education

Refer the patient to an endocrinologist for a detailed check-up. Give direction on stress-alleviation strategies like care, profound breathing activities, and participating in side interests or exercises that promote relaxation. Offer healthful guidance toward promoting a reasonable eating routine rich in organic products, vegetables, lean proteins, and whole grains while limiting processed foods and sweet bites.

Follow Up

A follow-up appointment will be scheduled after two weeks of referral to an endocrinologist.

References

Fitzgerald, A. A., & Weiner, L. M. (2020). The role of fibroblast activation protein in health and malignancy. Cancer and Metastasis Reviews. https://doi.org/10.1007/s10555-020-09909-3

Guerri, G., Bressan, S., Sartori, M., Costantini, A., Benedetti, S., Agostini, F., Tezzele, S., Cecchin, S., Scaramuzza, A., & Bertelli, M. (2019). Hypothyroidism and hyperthyroidism. Acta Bio Medica : Atenei Parmensis, 90(Suppl 10), 83–86. https://doi.org/10.23750/abm.v90i10-S.8765

Shah, A., Walker, M., Burger, D., Martin, N., von Wulffen, M., Koloski, N., Jones, M., Talley, N. J., & Holtmann, G. J. (2019). The link between celiac disease and inflammatory bowel disease. Journal of Clinical Gastroenterology, 53(7), 514–522. https://doi.org/10.1097/MCG.0000000000001033

Touyz, S., Lacey, H., & Hay, P. (2020). Eating disorders in the time of COVID-19. Journal of Eating Disorders, 8(1). https://doi.org/10.1186/s40337-020-00295-3

Cleveland Clinic. (2023). How thyroid tests can improve your health. Cleveland Clinic. https://my.clevelandclinic.org/health/diagnostics/17556-thyroid-blood- tests#:~:text=What%20blood%20tests%20show%20thyroid

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