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Evaluation of a 53-Year-Old Female Patient with TSH of 93: A SOAP Note Discussion

Subjective

You are evaluating a 53-year-old white female who wants to talk to you about lab work that she had done recently at “Any Lab Test Now”. She wanted to have lab work done because she was feeling tired and unmotivated. Additionally, she had put on about 15 pounds even though she has been teaching yoga 2-3 times a week for the last few years. The lab results reveal a TSH of 93. She reports her last menstrual period was about 3 years ago. She experienced some menopausal symptoms of hot flashes and night sweats. However, she states they weren’t too much of a problem and those resolved a couple years ago. She denies any difficulty swallowing or neck pain/tenderness. Constitutional exam: 5’5” tall, 154 pounds, BP 145/88, P 60, R 16, Temp 97.2 Neck – nontender, mild goiter with right side of thyroid larger than the left side Heart – regular rhythm without murmur or gallop Lungs – clear Skin – dry on extremities with some flaking noted A slowness of the relaxation phase of the Achilles tendon reflex is noted Please develop a discussion that responds to each of the following prompts. Where appropriate your discussion needs to be supported by scholarly resources.

Be sure to include in-text citations in the context of the discussion and provide a full reference citation at the end of the discussion. Initial post Utilize the information provided in the scenario to create your discussion post. Construct your response as an abbreviated SOAP note (Subjective Objective Assessment Plan). Structure your ‘P’ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the ‘heading’ and after the ‘:’ input N/A] Therapeutics: pharmacologic interventions, if any – new or revisions to existing; include considerations for OTC agents (pharmacologic and non-pharmacologic/alternative); [optional - any other therapies in lieu of pharmacologic intervention] Educational: health information clients need to address their presenting problem(s); health information in support of any of the ‘therapeutics’ identified above; information about follow-up care where appropriate; provision of anticipatory guidance and counseling during the context of the office visit Consultation/Collaboration: if appropriate - collaborative ‘Advanced Care Planning’ with the patient/patient’s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate – consult with or referral to another provider while the patient is still in the office; Identification of any future referral you would consider making Support the interventions outlined in your ‘P’ with scholarly resources.

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