You are evaluating a 53-year-old white female who wants to talk to you about lab work that she had done recently at â€œAny Lab Test Nowâ€.
- 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 werenâ€™t too much of a problem and those resolved a couple years ago.
- She denies any difficulty swallowing or neck pain/tenderness.
- Constitutional exam: 5â€™5â€ tall, 154 pounds, BP 145/88, P 60, R 16, Temp 97.2
- Neck â€“ nontender, mild goiter with right side of thyroid larger than the left side
- Heart â€“ regular rhythm without murmur or gallop
- Lungs â€“ clear
- Skin â€“ dry on extremities with some flaking noted
- A slowness of the relaxation phase of the Achilles tendon reflex is noted
Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).
Structure your â€˜Pâ€™ in the following format: [NOTE: if any of the 3 categories is not applicable to your plan please use the â€˜headingâ€™ and after the â€˜:â€™ input N/A]
Therapeutics:pharmacologic interventions, if any â€“ 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 in order to address their presenting problem(s); health information in support of any of the â€˜therapeuticsâ€™ 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 â€˜Advanced Care Planningâ€™ with the patient/patientâ€™s care giver; if appropriate -placing the patient in a Transitional Care Model for appropriate pharmacologic and non-pharmacologic care; if appropriate â€“ 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 â€˜Pâ€™ with scholarly resources.