Kali, a 44 year old female is in the office for a complete physical examination

Advanced Health Assessment (NURS 6512)

Kali, a 44 year old female is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and is overweight.

 Consider what history would be necessary to collect from the patient.

• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.
• Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study to which you were assigned using the episodic/focused note 

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Answer

3 days ago

When evaluating Kali, a 44-year-old female, who complains of proptosis and feeling fatigued, it is important to collect a thorough history to determine the possible causes of her symptoms. The following information should be gathered:

• Medical history, including any previous thyroid conditions, autoimmune disorders, or cancer
• Family history of thyroid disorders or autoimmune diseases
• Current medications and supplements
• Dietary habits and exercise routine
• Occupational and environmental exposures
• History of smoking or alcohol use

Physical exams and diagnostic tests that would be appropriate to gather more information about Kali’s condition include:

• Thyroid function tests, including TSH, free T4, and free T3
• Thyroid ultrasound to evaluate the size and appearance of the thyroid gland
• Antibody tests to evaluate for autoimmune thyroid disease
• Lipid panel to evaluate hyperlipidemia
• Complete blood count to evaluate for anemia or infection
• Glucose and insulin levels to evaluate for diabetes or insulin resistance
• Imaging studies, such as CT or MRI, to evaluate for tumors or other abnormalities in the neck or eye

The results of these tests would be used to make a diagnosis by evaluating Kali’s thyroid function, ruling out other possible causes of her symptoms, and identifying any underlying conditions that may be contributing to her symptoms. Possible conditions that may be considered in a differential diagnosis for Kali include:

• Graves’ disease
• Hashimoto’s thyroiditis
• Thyroid nodules or cancer
• Diabetes
• Cushing’s syndrome

Episodic/Focused SOAP Note:

S:

Kali is a 44-year-old female who presents with complaints of proptosis and feeling fatigued. She reports a history of hyperlipidemia and elevated TSH levels. She also reports a swollen neck and being overweight.

O:

Vital signs: BP 130/80, HR 80, RR 16, Temp 98.6°F

General: Overweight female in no acute distress

Head, Eyes, Ears, Nose, and Throat: Proptosis noted, neck appears swollen

Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops

Respiratory: Clear to auscultation bilaterally

Gastrointestinal: Soft, non-tender, non-distended abdomen

Extremities: No edema or clubbing

A:

1. Proptosis

2. Elevated TSH levels

3. Hyperlipidemia

4. Swollen neck

5. Overweight

P:

1. Order thyroid function tests, including TSH, free T4, and free T3

2. Order thyroid ultrasound to evaluate the size and appearance of the thyroid gland

3. Order antibody tests to evaluate for autoimmune thyroid disease

4. Order lipid panel to evaluate hyperlipidemia

5. Refer to endocrinologist for further evaluation and management