+1443 776-2705 panelessays@gmail.com

Hello I need to use the attached SOAP NOTE into the template provide as well. This SOAP note is done on a well patient. So please don’t put any abnormalities. ITs a wellness check up. and the assignment is a head to toe assessment. 

1

Running Head: HEAD TO TOE ASSESSMENT

2

HEAD TO TOE ASSESSMENT

Head to toe assessment

Ralph Marrero

South University

NSG6020

Dec 6, 2021

The following is a complete head to toe assessment of 32-year-old women, presenting to the office for a wellness checkup. I performed hand hygiene and introduced myself to the patient. Asked orientation questions as well as some subjective questions. Patient states having no distress or pain currently. Vital signs: Height 5’4’’, weight 195 pounds, B/P: 120/80 mm Hg, Breathing: 16 breaths per minute, Pulse: 85 beats per minute, Temperature: 98.3°F. The patient’s vital signs are within normal limits.
General appearance: Patient seems to be in overall good health and good hygiene. Patient is alert and oriented x4. Skin, nails, and hair: Skin pink, warm, dry and elastic. No lesions or excoriations noted. Hair brown, shoulder length, clean, shiny. Normal distribution of hair on scalp. Nails are hard, smooth, and clean cut. Nailbeds pink without clubbing. Cuticles smooth. Hands well- manicured with clear enamel. HEAD AND NECK: Head and neck are symmetrical. Patient dienes any tenderness, bumps nor burses on the head or neck. Head symmetrically round and smooth without lesions or bumps. Face oval, smooth, and symmetrical. Neck symmetric with centered head position and no bulging masses. Has smooth, controlled, full range of motion of neck. Trachea in midline. Lymph nodes nonpalpable. EYES AND EARS: No redness, discharge, or crusting noted on lid margins. Conjunctiva and sclera appear moist and smooth. Sclera white with no lesions or redness. Irises are round, flat, and evenly colored. Pupils are equal in size and reactive to light and accommodation. Pupils converge evenly. Ears are equal in size bilaterally. Denies ear pain, discharge, problems in general. external ear intact. Skin smooth, no lumps, lesions, nodules. No discharge. Nontender on palpation. NOSE AND SINUSES: Patient denies any congestion, drainage, pain, nor discomfort. Upon inspection of nostrils appear symmetry. frontal and maxillary sinuses have no tenderness. Lips pink, smooth, and moist without lesions. Oral cavity pink, moist, and without exudates. 32 white to yellowish teeth present. Gums pink without redness or swelling. Equal bilateral strength in tongue noted. SHOULDERS AND UPPER EXTERMITIES: shoulders and clavicles ARE symmetry and NO deviation, Brachial, and radial arteries +2, strength 5/5. CHEST AND LUNGS: Patient denies chest pain, palpitations, edema, tachycardia. Chest movements are bilateral and symmetric. Noted no bruits, murmurs, or clicking. Noted to have regular rate and rhyme. Carotid pulse equal bilaterally, 2+. Distinct and strong. No presence of JVD. Apical pulse palpated in the fifth ICS at the left MCL. Breath sounds clear bilaterally. No wheezing, crackles, or rhonchi. ABDOMEN: There was no soreness, tenderness, or abdominal swelling. No aortic tenderness bowel sounds present in all four quadrants. Extremities: The patient’s handgrip and foot strength were symmetrical. There were no pressure areas on any of his limbs and their movement was coordinated. The pulses were uniform in rate and rhythm. Strength is 5/5. Gait smooth, with equal stride bilaterally. Normal curves of cervical, thoracic, and lumbar spine. Full smooth ROM of cervical and lumbar spine, no crepitus present. Upper and lower extremities symmetric without lesions, nodules, deformities, or swelling. Full smooth ROM against gravity and resistance.

SOAP NOTE

Name: 

Date:

Time:

 

Age: 29 years

Sex: Female

SUBJECTIVE

CC: 

“I always feel tired.”

HPI: O- the patient has had this issue for six months. L– on the neck. D– daily, the client thought that the pain would go away. C-she rates the pan to be 5/10. A– no aggravating factor was mentioned. R– non. T– non. S– the patient state that the pain is constant.

 

Medications: ortho tri-cyclen 28 1 PO every day.

PMH:

Allergies: NKDA

Medication Intolerances: none

Immunizations: up to date

Chronic Illnesses/Major traumas: the patient has no any condition except the one that made her come to hospital which is lethargic, tired, and fuzzy-headed.

Hospitalizations/Surgeries; non-contributory.

 

Family History- her father, has type 1 diabetes.

 

Social History- the patient is 29 years old female, and she is married ad; she denies using any illicit drugs, and she does not smoke, but she states that she drinks wine socially.

 

ROS

General

 The patient states that she has been feeling tired, lethargic, and fuzzy-headed for the past six months, and she also says that her skin has become drier and itchier.

Cardiovascular

 She states that she has been experiencing chest pains.

Skin

 The patient states that her skin is itchier and drier

Respiratory

The patient states that she has been having deeper and more rapid breathing.

 

Eyes

 No pain of her eyes

Gastrointestinal

No diarrhea, vomiting, or nausea and have normal appetite.

 

Ears

 normal

Genitourinary/Gynecological

No vaginal discharge, irritation or discomfort while urinating.

Nose/Mouth/Throat

 No pain on her mouth, throat and nose. There is no change in the sense of smell, and she has no pain in the nose.

Musculoskeletal

She complains of muscle pain.

Breast

normal.

Neurological

The patient states that she has been feeling fuzzy on her head.

Heme/Lymph/Endo

No bruising or bleeding.

Psychiatric

No changes on her mood; denies depression, anxiety or insomnia. No suicidal thoughts.

OBJECTIVE

Weight: 130lb BMI:

Temp: 36.4C

BP: 142/89 mm/hg

Height: 5.8”

Pulse: 64

Rep: 18/min

General Appearance

The patient is dressed properly, she is oriented and alert and she answers the questions in the right way. She is 29 years old patient and she is shivering, and her skin and scalp are dry. She has no thyroid nodules or goiter, no lymphadenopathy.

Skin

The skin is dry, and the patient states that it is itchy.

HEAT

Normal



Cardiovascular

The patient has a rapid heart rate.

Respiratory

The patient accepts that she has shortness of breath.

Gastrointestinal

normal

Breast

normal

Genitourinary

No itching on the vagina, no pain when urinating, no vaginal discharge and discomfort.

Musculoskeletal

normal

Neurological

The patient has clear speech, she is cooperative, alert and she have coherent thoughts.

Psychiatric

Her behavior is appropriate according to her age.

Lab Tests

Blood test- pending

Special Tests



 Diagnosis

Primary Diagnosis- hyperthyroidism (ICD-10 E05)

Hyperthyroidism happens when the thyroid gland generates too much of the hormone thyroxine. This condition can hasten the metabolism of the body, and this can cause unintended weight loss and an irregular or rapid heartbeat. This condition can mimic other health issues, making it hard for the doctor to diagnose (Pou Ucha, 2014). Some of the symptoms of this condition include rapid heartbeat, usually more than 100 beats a minute, unintended weight loss, irregular heartbeat, pounding of the heart, increased appetite, tremor, nervous, anxiety, and irritability, sweating, fatigue, muscle weakness, skin thinning, increased sensitivity to the heart, etc. Older adults are more likely to have either no symptoms or signs.

Differential Diagnoses

1. Grave Disease (ICD-10 E05.00)

This condition is an immune system disease that is caused by the thyroid hormones overproduction. Thyroid hormones impact most body systems, so the symptoms and signs of this disorder can be broad (Layla Alhasan, 2019). Even though the disease can impact anyone, it is more common among women and in people who are younger than forty years. Some of the symptoms of this condition include weight loss regardless of normal eating, anxiety and irritability, the thyroid gland enlargement, fatigue, bulging eyes, erectile dysfunction, sensitivity to heat, and an increase in diaphoresis or warm moist skin, frequent bowel movements, etc.

2. Addison’s disease (ICD-10 E27.1)

This is not a common disorder and takes place when the body does not generate adequate specific hormones. In this disease, the adrenal glands that are above the kidneys generate too little cortisol and mostly too little aldosterone. The signs of this condition typically grow slowly, mostly over several months. Some of the symptoms of this condition include extreme fatigue, low blood pressure and fainting, weight loss and decreased appetite, salt craving, abdominal pain, irritability, joint or muscle pain, darkening of the skin, nausea, vomiting, or diarrhea, sexual dysfunction in women, etc.

3. Chronic Fatigue Syndrome (ICD-10 R53.82)

This is a disorder that is very complicated and is characterized by acute fatigue that lasts for at least six months, and that cannot be fully explained by the underlying medical condition (JOSEPH R. YANCEY, 2012). The fatigue becomes worse with mental or physical activity, but it does not improve with the rest. Some of the symptoms include fatigue, headaches, extreme exhaustion after mental or physical exercise, unexplained joint or muscle pain, sore throat, enlarged lymph nodes on the neck or armpits, dizziness that becomes worse with moving from lying down or sitting to standing, etc.

Plan/Therapeutics

The care plan for this condition is to substitute with thyroid hormone. In this case, retesting the thyroid levels is essential, and having an ultrasound of the thyroid gland to ensure that it is not any nodules or tumors causing the elevated TSH levels. The main objective of the treatment for this patient is to regress her to a TSH span of 0.5 to 4.0mIU/mL. For thyroid disease, the medication therapy usually is permanent, except for the patient with thyroiditis from acute hypothyroid or pregnancy. To care for this patient, the care provider needs to begin on a replacement hormone for thyroid disorders which is levothyroxine. This can take six to eight weeks of medication use to get the TSH levels in the proper range; it might take the patient like a week or even longer to relieve their indicators of hypothyroidism.

Education- the patient with this condition will be educated on the importance of taking levothyroxine for their lifetime. To notice the improvement in their symptoms, it will take the patient two to four weeks. The patient will also be educated on the importance of frequent TSH levels to be checked to ensure that the medication therapy is working and that the unwavering TSH level is attained and should be checked again yearly.

References

JOSEPH R. YANCEY. (2012, October 15). AAFP American Academy of Family Physicians.
https://www.aafp.org/afp/2012/1015/afp20121015p741.pdf

Layla Alhasan. (2019). Histopathological exploration & morphological changes of the thyroid gland with the grave disease. The University of Thi-Qar Journal.
https://doi.org/10.32792/utq/utj/vol13/4/3

Pou Ucha, J. L. (2014). Imaging in Hyperthyroidism. Thyroid Disorders – Focus on Hyperthyroidism.

1