Case Study For Proptosis And Fatigue Assignment

Case Study For Proptosis And Fatigue Assignment

Focused SOAP Note
Patient Information:
K.K, 44, Female, African American
S.
CC: proptosis and fatigue
HPI: K.K. is an African American woman of 44 years of age who comes to the clinic in order to get a comprehensive medical examination. Her complaints include proptosis and extreme fatigue. There is visible neck swelling, hyperlipidemia, and increased TSH levels. According to her account, she began experiencing feelings of exhaustion around three weeks ago, and the issue has become more severe during the previous two days. She describes related symptoms such as cramping in her muscles and joints, as well as weakness. Despite having less of an appetite, she has seen a considerable increase in her weight. She estimates that she has gained around 30 pounds in the last year, and she is putting a lot of effort into reducing the weight that she has acquired.
Current Medications: Bupropion-naltrexone 90mg/8mg once daily for weight loss Case Study For Proptosis And Fatigue Assignment

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Allergies: Reports penicillin allergy
PMHx: immunizations are current. Received all childhood immunizations. Reports history of GERD and hyperlipidemia.
Soc Hx: K.K. makes her income as the proprietor of a grocery store. She is divorced and lives with her three children. Her hobbies include cooking and watching telenovelas. She says that she does not use alcohol, cigarettes, or illegal substances.
Fam Hx:
Mother: deceased at age 69 of breast cancer.
Father: age 72, history of hypertension.
Sister: age 48, history of arthritis
ROS:
GENERAL: Reports fatigue, weakness, and weight gain and. Denies fever or chills.
HEENT: Eyes: Reports bulging eyes. Ears, Nose, Throat: Denies ear pain, hearing loss, sinus pain, nasal congestion, rhinorrhea or sore throat.
SKIN: Denies rash, lesions, or itching.
CARDIOVASCULAR: Denies chest pain, irregular heartbeat, palpitations or edema.
RESPIRATORY: Denies respiratory distress, wheezing, shortness of breath, or cough.
GASTROINTESTINAL: Denies abdominal pain, anorexia, vomiting, nausea, constipation or diarrhea.
GENITOURINARY: Denies incontinence, hesitancy, hematuria, or pain on urination.
NEUROLOGICAL: Denies dizziness, headaches, numbness or tingling, paralysis, syncope, or ataxia. Denies change in bladder or bowel control.
MUSCULOSKELETAL: Denies muscle pain, back pain, joint pain or stiffness.
HEMATOLOGIC: Denies bruising, anemia, or bleeding.
LYMPHATICS: Reports swelling on the neck. Denies history of splenectomy.
PSYCHIATRIC: Denies history of depression, anxiety, or other mental illnesses.
ENDOCRINOLOGIC: Denies polydipsia or polyuria. Denies excessive sweating or cold or heat intolerance.
ALLERGIES: Denies history of rhinitis, eczema, hives, or asthma.
O.
Physical exam:
Vital signs: H 5’4”, W 195 lbs, RR 17, HR, 76, BP 126/76, 02 Sat 98%
HEENT: Bulging of both eyes noted. Intact ears with good reflex. Thyroid gland appears swollen.
Diagnostic results:
Hemoglobin A1C, TSH, and thyroid antibody test results pending Case Study For Proptosis And Fatigue Assignment
A.
Differential Diagnoses
1. Graves’ disease: Graves’ disease is an autoimmune condition in which healthy tissue in the thyroid gland is attacked by the body’s immune system for reasons that are not fully understood. It is by far the most prevalent reason for hyperthyroidism, which is a disease in which the thyroid gland produces an excessive amount of the hormone thyroid hormone. Graves’ disease affects more persons who were given the feminine gender at birth than it does those who were given the male gender. Although it most often affects persons between the ages of 30 and 50, it may also strike younger people and others much farther along in life (Wiersinga, 2019). If a person has a history of thyroid illness in their family or smokes cigarettes, they have a greater chance of having Graves’ disease themselves. Graves’ illness often presents itself in a manner that is slow-moving, with symptoms not becoming apparent for many weeks or even months at a time. Anxiety, hand tremors, sensitivity to heat, loss of weight, bulging eyes, and an enlarged thyroid are some of the symptoms of an enlarged thyroid. People who have this disorder are also more likely to develop symptoms such as excessive sweating, weariness, an intolerance to heat, or high blood pressure. Graves’ disease may be treated by reducing the quantity of thyroid hormone that is produced in the body or by blocking the activity of thyroid hormone. This illness may be treated in a number of ways, the most common of which are the administration of antithyroid medication, treatment with radioactive iodine, and surgical removal of the thyroid. Graves’ disease, if left untreated, may result in a number of other health complications, such as thyroid storm, cardiovascular issues, bone loss, and complications during pregnancy.
2. Hyperthyroidism: Hyperthyroidism is the medical term for the condition that occurs when the thyroid gland produces an abnormally high level of the hormone thyroxine. A number of different diseases, such as Graves’ disease, Plummer’s disease, and thyroiditis, are among the conditions that have the potential to bring on hyperthyroidism in a patient. It is a disorder in which the body’s metabolism speeds up, which causes unexpected weight loss in addition to an irregular or rapid heartbeat. It is called hypermetabolic syndrome. Because the symptoms of hyperthyroidism can be indistinguishable from those of other medical conditions, it can be challenging for a physician to diagnose the condition. It is also possible for it to cause a wide variety of signs and symptoms, some examples of which include accidental weight loss, a quick pulse, perspiration, tremor, weariness, and increased sensitivity to heat. Persons under the age of 65 are less likely than older those to exhibit any signs or symptoms at all. This is especially true for people over the age of 65. A rapid heartbeat, an intolerance to heat, and a predisposition to fatigue easily when doing routine activities are typical manifestations of this condition (Taylor et al., 2018). There are several potential treatments available for hyperthyroidism. The use of anti-thyroid medications as well as the ingestion of radioactive iodine that is prescribed by medical professionals both have the effect of lowering the rate at which thyroid hormones are produced. Hyperthyroidism may sometimes be treated by surgical removal of all or portion of the thyroid gland. The vast majority of individuals who are diagnosed with hyperthyroidism and get treatment for it have a good outcome. On the other hand, untreated hyperthyroidism may pose a serious risk to one’s life.
3. Thyroid hormone resistance: Thyroid hormone resistance is a hereditary disorder that affects one in every 40,000 live births. This illness is defined by a decreased responsiveness of target tissues to thyroid hormone, which is caused by mutations on the thyroid hormone receptor. It is possible that this illness may not be associated with any symptoms at all, or that it will be associated with symptoms of either an underactive or overactive thyroid gland. The amount of thyroid hormone in the blood is higher than normal because the pituitary gland, which is responsible for regulating the production of hormones from the thyroid gland, is not being appropriately shut down by the thyroid hormone (Singh & Yen, 2017)Case Study For Proptosis And Fatigue Assignment. The swelling of the thyroid gland could be the consequence of an abnormally high level of thyroid hormone production. Peripheral tissues may develop resistant to the effects of thyroid hormones when they are subjected to high concentrations of the hormones; yet, they can also maintain their sensitivity, which can result in symptoms associated with both an overactive or underactive thyroid. When treating individuals who have this condition, the primary focus of treatment should not be on normalizing thyroid hormone levels but rather on the individual ‘s symptoms and overall clinical presentation. The majority of patients are able to successfully combat the resistance on their own via increased thyroid hormone production, and as a result, they do not need to be treated. The treatment of individuals who come with normal TSH levels is more difficult. In such individuals, the administration of supraphysiological amounts of thyroid hormone may be necessary; if this is the case, the patient’s condition should be carefully watched (Sun et al., 2020). According to their major symptoms, individuals who exhibit hyperthyroidism symptoms should get symptomatic treatment with beta-blockers or antianxiety drugs, among other treatments.
References
Singh, B. K., & Yen, P. M. (2017). A clinician’s guide to understanding resistance to thyroid hormone due to receptor mutations in the TRα and TRβ isoforms. Clinical diabetes and endocrinology, 3(1), 1-11. https://doi.org/10.1186/s40842-017-0046-z
Sun, H., Cao, L., Zheng, R., Xie, S., & Liu, C. (2020). Update on resistance to thyroid hormone syndromeβ. Italian Journal of Pediatrics, 46(1). https://doi.org/10.1186/s13052-020-00929-x
Taylor, P. N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J. H., Dayan, C. M., & Okosieme, O. E. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology, 14(5), 301-316. https://doi.org/10.1038/nrendo.2018.18
Wiersinga, W. M. (2019). Graves’ disease: Can it be cured? Endocrinology and Metabolism, 34(1), 29. https://doi.org/10.3803/enm.2019.34.1.29 Case Study For Proptosis And Fatigue Assignment

Episodic/Focused SOAP Note Template

Patient Information:

Initials, Age, Sex, Race

CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patient’s own words – for instance “headache”, NOT “bad headache for 3 days”.

HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was “headache”, the LOCATES for the HPI might look like the following example:

Location: head

Onset: 3 days ago

Character: pounding, pressure around the eyes and temples

Associated signs and symptoms: nausea, vomiting, photophobia, phonophobia

Timing: after being on the computer all day at work

Exacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely better

Severity: 7/10 pain scale

Current Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance)Case Study For Proptosis And Fatigue Assignment.

PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed

Soc Hx: include occupation and major hobbies, family status, tobacco & alcohol use (previous and current use), any other pertinent data. Always add some health promo question here – such as whether they use seat belts all the time or whether they have working smoke detectors in the house, living environment, text/cell phone use while driving, and support system.

Fam Hx: illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent.

ROS: cover all body systems that may help you include or rule out a differential diagnosis You should list each system as follows: General: Head: EENT: etc. You should list these in bullet format and document the systems in order from head to toe.

Example of Complete ROS:

GENERAL: Denies weight loss, fever, chills, weakness or fatigue.

HEENT: Eyes: Denies visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: Denies hearing loss, sneezing, congestion, runny nose or sore throat Case Study For Proptosis And Fatigue Assignment.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY: Denies shortness of breath, cough or sputum.

GASTROINTESTINAL: Denies anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.

GENITOURINARY: Burning on urination. Pregnancy. Last menstrual period, MM/DD/YYYY.

NEUROLOGICAL: Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL: Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC: Denies anemia, bleeding or bruising.

LYMPHATICS: Denies enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies history of depression or anxiety.

ENDOCRINOLOGIC: Denies reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES: Denies history of asthma, hives, eczema or rhinitis.

Physical exam: From head-to-toe, include what you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History. Do not use “WNL” or “normal.” You must describe what you see. Always document in head to toe format i.e. General: Head: EENT: etc.

Diagnostic results: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses (support with evidenced and guidelines)Case Study For Proptosis And Fatigue Assignment

Differential Diagnoses (list a minimum of 3 differential diagnoses).Your primary or presumptive diagnosis should be at the top of the list. For each diagnosis, provide supportive documentation with evidence based guidelines.

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This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.

References

You are required to include at least three evidence based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 7^th edition formatting Case Study For Proptosis And Fatigue Assignment

This week, you will explore how to assess the head, neck, eyes, ears, nose, and throat. Whether dealing with a detached retina, sinusitis, meningitis, or even cough, advanced practice nurses need to know the proper assessment techniques in order to form accurate diagnoses.

Learning Objectives

Students will:

Apply assessment skills to diagnose eye, ear, and throat conditions

Apply concepts, theories, and principles relating to health assessment techniques and diagnoses for the head, neck, eyes, ears, nose, and throat.

Most ear, nose, and throat conditions that arise in non-critical care settings are minor in nature. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment. In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.
With regard to the case study you were assigned:

Review this week’s Learning Resources and consider the insights they provide.
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.

The Assignment
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 template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. List five different possible conditions for the patient’s differential diagnosis and justify why you selected each.

Case Study 2: Focused Thyroid Exam (Student last name N-Z)

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.