NU636 Unit 4 treatment of hypothyroidism

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

Construct your response as an abbreviated SOAP note (SubjectiveObjectiveAssessmentPlan).

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 in order 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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