SOAP Note- Assessment and Management of a Common Respiratory or Cardiovascular Condition

SOAP Note- Assessment and Management of a Common Respiratory or Cardiovascular Condition

ID:

Client’s Initials*:SC_Age__78___ Race____Caucasian______Gender____Male________Date of Birth__Jan 1,1946________

Insurance _United Healthcare Marital Status___Married__________

The Patient is accompanied by his wife to the clinic. He is responsive and reliable in sharing his health and medical information. His wife is also an important source of information.

Subjective:

CC: “I have been experiencing unusual fatigue and coldness for some time.”

HPI: SC is a 78-year-old Caucasian male presenting to the clinic with complaints of unusual fatigue and cold intolerance. He also reported having gained 20 pounds over the last year despite not assuming a sedentary lifestyle and eating out of his normal diet. The patient also reported episodes of sleep disturbances most of the night. The onset of his complaints was about a year ago, and he has been progressing ever since. He feels unusually cold in his entire body, especially in the extremities. This has always prompted him to wear a jacket, even in hot weather. His symptoms are aggravated after consuming some meals and relieved by rest. He notes that the last time he took his favorite fish meal, his symptoms became severe. The symptoms appear most times of the day but are particularly severe in the morning and evening. Collaborative history from the wife revealed that the patient has been having some bouts of memory lapses recently.

Past Medical History:

• Medical problem list

Type 2 Diabetes Mellitus for four years. He is on antidiabetic medications.

Hypertension for two years. He is currently on antihypertensive medications.

• Preventative care:

Prostate examination in January 2024, with no abnormalities noted.

A dental checkup in December 2023 revealed no dental carries or abnormalities in his dental cavity.

Takes the annual flu vaccine and has received his booster shot for the COVID-19 vaccine.

• Surgeries: Denies any surgical history.
• Hospitalizations: Hospitalized in 2020 for hypoglycemia after mistakenly taking an overdose of his anti-diabetic medications. He was also hospitalized after an involvement in a road accident on his 20th birthday.

Allergies: No known drug or food allergies.

Medications: The patient is currently on metformin 1g Taken, orally every 12 hours for the management of his diabetes. The patient is also taking enalapril 5mg, taken orally every 24 hours for the management of high blood pressure. He is also taking unidentified over-the-counter medications recommended to him by his brother to boost his appetite.

Family History: Mother is alive but diabetic. His father is also a known hypertensive.

Social History:

Sexual history and contraception/protection: The client is sexually active. He engages in sexual intercourse with his wife. He denies using any form of contraceptives.

Chemical history (tobacco/alcohol/drugs): The patient is a social smoker. He smokes during social events. He also consumes alcohol periodically. He denies having used any illicit substances or narcotics.

Others: The patient engages in physical activities and exercises regularly. He is a lover of seafood and incorporates a fish diet in almost all of his meals. He takes two cups of coffee every day. He is spiritual. He mediates every morning before beginning the activities of the day and prays frequently. He is a staunch Catholic who subscribed to the Christian values and beliefs. The patient lives with his wife and three children. The patient can also execute all daily activities independently. He works as a social worker in a local nursing home. He lives with his wife in a safe neighborhood.

ROS

Constitutional: The patient reports recent weight gain and unusual feelings of cold and fatigue. He denies having any fever or chills.

Eyes: Denies any visual loss, blurriness, or double vision. Also denies having had any eye infection or unusual discharge or tearing recently.

Ears/Nose/Mouth/Throat: No reports of hearing loss, or use of hearing aids, tinnitus, or ear discharge. There were also no reports of nasal discharge, swelling, or anosmia. He denied experiencing unusual dryness in his mouth. The patient reported experiencing an unusual deepening of his voice. He also reported having on-and-off episodes of neck pains.

Cardiovascular: No reports of palpitations, chest discomfort or pain, or edema in his extremities.

Pulmonary: No reports of wheezing, cough, and shortness of breath.

Gastrointestinal: The patient reported experiencing multiple episodes of constipation recently. He denied having any bowel distension, abdominal pain, or tenderness.

Genitourinary: No reports of urinary hesitancy, frequency, urgency, or dysuria.

Musculoskeletal: The patient reported occasional muscle cramps. He denied any restrictions in his range of motions.

Integumentary & breast: No reports of breast tenderness or swelling. He noted that his skin is unusually dry prompting him to apply a moisturizer on the skin. He denies having any skin color changes. He also denied having any scars, nodules, or rashes on his skin.

Neurological: There were no reports of dizziness, syncope, or seizures.

Psychiatric: No reports of depression, anxiety, or any other mental health illness.

Endocrine: The patient reported being cold intolerant. He is also a known diabetic patient.

Hematologic/Lymphatic: no reports of splenectomy, bleeding, or bruising. There were also no reports of lymph swelling.

Allergic/Immunologic: The patient has no known allergies.

Objective

Vital Signs:

HR: 65 beats per minute

BP: 110/60mmHg

Temp: 96.8 degrees

RR 19 breaths per minute

SpO2 95%

Height: 160cm

Weight 95kgs

BMI: 37.1 kg/m2

 Laboratory Findings

Complete Blood Count for SC on 7/4/2024

Hematology	Result	Normal range
Red cell count	5.5 x 1012/L	4.5–5.7
White cell count	9.8 x 109/L	4.0–10.0
Hemoglobin	151 g/L	133–167
Hematocrit	0.42	0.35–0.53
MCV	85 fL	77–98
MCH	29.4 pg	26–33
MCHC	360 g/L	330–370
RDW	14.5%	10.3–15.3

Physical Exam

General survey: The patient is alert and responsive to the interview questions asked. He also answers them appropriately. He seems fatigued and sometimes slow in his speech and body movements. There are no signs of chills or fever.

Eyes: The eyes are symmetrical. No signs of eye discharge.

HEENT: The head is normocephalic. No signs of head swelling, lesions, or depressions. The scalp is normal, with no signs of alopecia, hair thickening, or scaling. The ears are symmetrical, warm to the touch, and consistent in coloration. There are no signs of discharge, swelling, or tenderness in the ears. The nose is midline on the face. Its coloration is consistent with other parts of the face. There is no sign of nasal swelling, discharge, tenderness, or deviation. The mouth is symmetrical. There is no sign of denture application or any tooth anomalies. There is no sign of tonsillar swelling.

Neck: The neck is symmetrical. It is consistent in color with the chest and face. The trachea is mid-line in the neck. There is a visible mass on the left side of the neck. There are no signs of discomfort on moving the neck in either direction.

CVS: The heart rate is low, as revealed by the vital sign report. There is no sign of jugular vein distention. There are also no signs of edema on the extremities.

Respiratory: The chest is symmetrical. There is no sign of chest deformity or use of accessory muscles during breathing. There is also no wheezing sound, respiratory crackles, or pericardial friction rub on auscultation. Palpitation of the chest revealed no pain, tenderness, or discomfort.

Abdomen/GI: The abdomen is symmetrical and well-rounded. There is no sign of abdominal distension. No masses, abdominal pain, or tenderness is observed on light and deep palpation of the abdomen. Bowel sounds were heard on auscultation of the right upper, right lower, left lower, and left upper quadrants.

Breast: There are no signs of breast nodules, masses, tenderness, or pain on palpation.

M/S: There are no signs of joint mobility restrictions or limitations, pain in moving the joints, or muscle stiffness and pain.

Lymph: There is a notable swelling in the neck. There are no signs of lymphatic swelling in other parts of the body.

Neurological: The patient is alert and oriented to the place, time, and event. He is responsive and fully aware of his surroundings. The patient is properly dressed for the occasion. He demonstrates goal-directed and logical judgment and speech. There are no signs of speech delays or slurry speech. His memory is normal, as he can recall the events at the beginning of the interview. His effect is euthymic.

Assessment

Differentials 

1. Hypothyroidism ICD-10 E03.9: Hypothyroidism is a condition resulting from low levels of thyroid hormone. It has a multifactorial etiology. Primary hypothyroidism is a result of inadequate production of thyroid hormone. Autoimmune thyroid disease is the most commonly implicated causal factor for hypothyroidism in the US. People with hypothyroidism often report complaints of fatigue, dryness of the skin, constipation, cold intolerance, sleep disturbances, and muscle cramping, among others. A painless nodular enlargement is a common finding in physical examination of patients with the condition. Additionally, vital signs in hypothyroidism are significant because of decreased heart rate (Jansen et al., 2023). The patient in the case presented with symptoms of fatigue, constipation, cold intolerance, sleep disturbances, and muscle cramping. A physical examination of the patient revealed a painless nodular swelling in the neck region. The vital signs were significant for a depressed heart rate. These presentations meet the criteria for diagnosing hypothyroidism.
2. Anemia ICD-10 D64.9: Anemia is a condition characterized by a reduction in hemoglobin count. It is usually a manifestation of an underlying condition. Anaemia has a multifactorial etiology. Iron deficiencies, lead poisoning, thalassemia, multiple myeloma, liver disease, medications, and hemoglobinopathies are some of the potential causal factors for anemia. In the comprehensive management of anemia, interrogating the underlying cause of the anemia is important. This is because anemia is a symptom of an active disease and can be managed by addressing the underlying cause. Patients with anemia will often present with complaints of fatigue, weakness, lethargy, and restless legs, among others (Chaparro & Suchdev, 2019). The patient in the case presented with complaints of weakness and fatigue. Physical examination affirmed the fatigue. Additionally, he had leg cramping, which may sometimes be associated with some anemias. This warranted the inclusion of this differential. It was, however, ruled out due to the absence of other features that are supportive of the diagnosis. A Complete blood count may be necessary to further rule out the diagnosis.
3. Thyroid lymphoma ICD-10 C73: Thyroid lymphoma is a rare thyroid malignancy. In primary thyroid lymphoma, the thyroid gland is affected first. Persons with thyroid lymphoma typically present with a rapidly enlarging thyroid gland, dysphagia, neck pain, and facial edema. Primary thyroid lymphoma often proceeds to Hashimoto thyroiditis. Systemic symptoms such as fatigue, cold intolerance, hoarseness of the voice, and constipation may also be apparent (Sakhri et al., 2024). The patient, in this case, presented with symptoms of fatigue, cold intolerance, hoarse voice, neck pain, and constipation. These symptoms are similar to those of thyroid lymphoma warranting the inclusion of thyroid lymphoma in the differentials list. Imaging and pathological tests are necessary to rule out this diagnosis.

Diagnosis: The Presumptive diagnosis in the case is hypothyroidism. Subjective and objective findings revealed features consistent with those in hypothyroidism. These are cold intolerance, fatigue, muscle cramping, sleep disturbance, dryness of the skin, nodular swelling in the neck region, and hoarseness of the voice. Core biopsy and imaging results revealed a non-cancerous nodular swelling, ruling out thyroid lymphoma. CBC with differential revealed normal red blood cells and hematocrit levels, ruling out anemia.

Plan

Hypothyroidism

Diagnostics: 

Serum TSH levels: Serum TSH levels are necessary for screening primary hypothyroidism. The normal serum TSH levels are 0.5 to 5.0 mIU/L. In primary hypothyroidism, TSH levels are elevated, while the serum T4 levels are low. However, in sub-clinical hypothyroidism, the T4 levels are normal. Assessing serum TSH levels is usually the first line of diagnostic assessment in the comprehensive management of hypothyroidism (Zamwar & Muneshwar, 2023).

Laboratory workup: Lab workup in hypothyroidism may reveal marked elevation in serum creatinine kinase (Normal 55 to 170 U/L in male adults), elevated hepatic enzymes, marked elevation of the BUN (Normal: 5 to 20 mg/dl) and uric acid levels (normal3.5 and 7.2 mg/dL). These findings are suggestive of but not confirmatory of hypothyroidism. They may, however, reveal the presence of an inflammatory process that may point towards the Hashimoto thyroiditis diagnosis.

Treatment: The mainstay therapeutic modality in hypothyroidism is replacement therapy with levothyroxine monotherapy. Levothyroxine replacement at a dose of 1.6mcg per kg per day maintains effectiveness in alleviating hypothyroidism manifestations (Zamwar & Muneshwar, 2023). The patient in the case, presented will be started on 150 mcg per day.

Education: The patient in the case will be educated on the disease processes. Primary hypothyroidism is a progressive condition that requires lifelong replacement therapy with levothyroxine. He will also be educated on the anticipated side effects. The common side effects of the medication include fever, heat intolerance, skin rash, headache, and chest pain, among others. The patient should report symptoms of increased heart rate or palpitation as this may be indicative of an overdose. The patients should also be told to strictly adhere to the levothyroxine therapy for optimal health and clinical outcomes. If not managed properly, hypothyroidism may result in complications such as myxedema coma may be apparent.

Follow-Up: The patient is expected to return for a follow-up after one week of initiating therapy to help caregivers ascertain the effectiveness of the prescribed medications. Routine monitoring is necessary to help caregivers identify potential complications of the disease process, such as myxedema coma.

Anemia

Diagnostics:

Complete Blood Count: Low counts of red blood cells are indicative of anemia. The normal RBC results in adult males are 5 to 6 million cells per microliter (cells/mcL)

Esophagogastroduodenoscopy: This test is only recommended where there is a clinical suspicion of GI bleed. Excessive GI bleeding is a causal factor for anemia.

Colonoscopy: Hlps in ruling out lower GI bleed. It is only recommended where there is a clinical suspicion of lower GI bleeding.

Imaging: Necessary if internal hemorrhage or malignancy is expected. Imaging may help rule out a malignancy that may be causing the symptoms in the case presented.

Treatment: The goal of anemia management is to treat the underlying cause. Anemia attributed to blood loss can be managed through IV fluids, cross-matched packed red blood cells, and oxygen. Anemia due to nutritional deficiencies can be managed through oral supplementation of iron and IV iron. Bone transplantation is indicated for patients with anemia resulting from defective bone marrow. Likewise, anemia due to chronic illnesses such as kidney failure can be managed by treating the underlying cause.

Education: The patient will be educated on their condition. In this respect, they should be told about the potential cause of their condition and the significance of managing the underlying condition, as a way of addressing the anemia. They should also be educated on foods that can potentially boost the levels of iron in the blood. This includes meat, eggs, and poultry. Leafy vegetables and fruits also contain non-heme iron, which is supportive of an iron diet.

Follow-up: Patients with anemia should be told to report to the clinic if the symptoms fail to improve. This may help caregivers to assess the effectiveness of the selected therapy.

Thyroid lymphoma

Diagnostics:

Laboratory workup: Serum TSH levels can be ordered to help identify the presence of hypothyroidism that characterizes thyroid lymphomas. Elevated TSH levels, and low T3 and T4 are suggestive of Hashimoto thyroiditis. Hashimoto thyroiditis often precedes thyroid lymphomas. This test can thus show the risk level for developing the disease or have a clinical suspicion for the disease.

Imaging: Thyroid ultrasound is the recommended imaging technique when evaluating thyroid lymphoma. This imaging technique can show the presence of hypoechogenic areas in the thyroid gland that appear as pseudocysts. Computed tomography scans and magnetic resonance imaging may show extra-thyroidal spread, including tracheal invasion, and lymph node involvement. Positron emission tomography scans can be used in staging the disease.

Pathology: Tissue sampling through fine needle aspiration is a primary diagnostic procedure in thyroid lymphoma. The technique is, however, less sensitive. Core biopsy is a more sensitive technique that gives definitive diagnostic results for thyroid lymphoma.

Treatment: Treatment of thyroid lymphoma will depend on the stage and subtype of the tumor. A combination of radiotherapy and chemotherapy is preferred over monotherapy with chemotherapy for a limited stage. Radiotherapy is not preferred in metastatic disease (Sakhri et al., 2024). The chemotherapy regimen that is mostly used is Rituximab-cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP). Even with treatment, the prognosis of thyroid lymphoma is poor in advanced disease.

Education: The patient will be educated on the disease process, including the disease prognosis, to allow them to prepare for any eventualities. Caregivers should discuss the available chemotherapy options and their side effects with the patient. The R-CHOP regimen has the potential to cause anemia, increased risk of infections, bleeding, bruising, sore throat, and loss of appetite.

Follow-Up: The patient is expected to return for a follow-up before the initiation of the chemotherapy and after the chemotherapy rounds. The R-CHOP regimen is usually administered over two-week and three-week cycles. The three-week cycles are preferred.

References

Chaparro, C. M., & Suchdev, P. S. (2019). Anemia epidemiology, pathophysiology, and etiology in low‐ and middle‐income countries. Annals of the New York Academy of Sciences, 1450(1), 15–31. https://doi.org/10.1111/nyas.14092

Jansen, H. I., Boelen, A., Heijboer, A. C., Bruinstroop, E., & Fliers, E. (2023). Hypothyroidism: The difficulty in attributing symptoms to their underlying cause. Frontiers in Endocrinology, 14. https://doi.org/10.3389/fendo.2023.1130661

Sakhri, S., Zemni, I., Ayadi, M. A., Kamoun, S., Chargui, R., & Ben Dhiab, T. (2024). Primary thyroid lymphoma: A case series. Journal of Medical Case Reports, 18(1). https://doi.org/10.1186/s13256-024-04434-1

Zamwar, U. M., & Muneshwar, K. N. (2023). Epidemiology, types, causes, clinical presentation, diagnosis, and treatment of hypothyroidism. Cureus. https://doi.org/10.7759/

ORDER A PLAGIARISM-FREE PAPER HERE

We’ll write everything from scratch

---

Select a patient with a common condition(s) from your practicum experience this week. Submit a correctly formatted SOAP note on that patient in a Word document.

Just kindly create any SOAP notes on either respiratory or cardiovascular common conditions