Create an episodic/focused SOAP note about the patient in the case study to which you were assigned. Provide evidence from the literature to support diagnostic tests that would be appropriate for each case.

CASE STUDY 2: Focused Thyroid Exam

Chantal, a 32-year-old female, comes into your office with complaints of “feeling tired” and “hair falling out”. She has gained 30 pounds in the last year but notes markedly decreased appetite. On ROS, she reports not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.

With regard to the case study you were assigned:

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

Create an episodic/focused SOAP note about the patient in the case study to which you were assigned. 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.

Example Below:

ASSESSMENT of head, Neck Eyes, Nose, Throat: – description focused exam and focused SOAP note

Scenario Focused ear exam : 11 year old boy, complaint of mild ear ache for two days, head ache, congestion runny nose.

Ex: Focused Ear Exam Lab Tests/Exams and Results:
CBC-WNL

Ex: Focused Ear exam Differential Diagnosis (Dx):

1. Acute sinusitis- Infection, usually bacterial, of one or all of the paranasal sinuses
(Petersen, 2016). Some of the symptoms are loss of smell, facial pain, postnasal drip, anterior discharge, nasal obstruction (Petersen, 2016). The sinus does not transilluminate (Petersen, 2016).

2. Rhinovirus – according to Ball et al (2015), the disease is mostly associated with sinus infections, sore throats, and the common cold. The rhinovirus can also cause symptoms of sneezing, congestion, breathing difficulties, runny nose, and cough accompanies by loss of appetite, headache, weakness, fatigue, and muscle aches
(Petersen, 2016).

3. Allergic rhinitis- When the body is exposed to specific allergens, hay fever or allergic rhinitis occurs as an inflammatory response or reaction (Ball et al., 2015). Pollen is one of the most common allergens that cause allergic rhinitis. The symptoms can be uncomfortable and include runny nose, sneezing, and itchy, watery eyes (Petersen,
2016). An “allergic salute” is a physical sign described as “the characteristic gesture of a person with allergic rhinitis: rubbing his or her nose with the index finger” (Ball et al., 2015). Dark coloring around the eyes is another physical sign and is related to nasal congestion or vasodilation (Petersen, 2016).

4. Chronic Sinusitis- A common condition of inflammation and swelling of nasal cavities and passages that linger for at least eight weeks without relief from treatment (Petersen, 2016). The client who has this condition experience breathing difficulties because the nose has been blocked by mucus builds up interfering with drainage.

You
may have painful or swollen eyes which may cause headaches or facial pain (Hamilos, 2000). Symptoms of chronic sinusitis are less apparent and may include blockage or congestion of the nasal cavity, post-nasal drainage, reduced sense of smell, and fatigue (Hamilos, 2000). Sinus radiography indicates filled sinus cavities (Hamilos, 2000).

Last Completed Projects