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Hypothyroidism Soap Note Guide with Examples

A hypothyroidism SOAP Note is a structured method of documentation used by healthcare providers to record patient information, assessment, and treatment plans specifically for individuals with thyroid hormone deficiency.

SOAP is an acronym that stands for Subjective, Objective, Assessment, and Plan. This format allows for a comprehensive and organized approach to patient care, ensuring that all relevant information is captured and easily accessible for future reference.

Hypothyroidism SOAP Note Example on Template

Hypothyroidism Soap Note Guide with Examples
Data NeededData for this patient
Patient InitialsKS
Identifying Data2/22/1959
Source and ReliabilityPatient and reliable.
Age63
GenderMale
OccupationRetired air force housing specialist.
Marital StatusWidowed
Subjective
Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – it may be a brief summary of the reason the patient wanted to be seen for this visit“I cannot stop gaining weight although I am active. I have had swelling in hand and feet, feeling cold, muscle cramps, and constipation in the past two months.”
History of Present Illness: Allergies: medications, food, environmental or seasonalChildhood Illnesses: chicken pox, rheumatic fever, rubella, measles, and mumpsAdult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric Health Maintenance Immunization status: DPT, MMR, influenza, hepatitis, polio, Pneumovax, herpes zoster Dental exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results)KS is a 63-year-old African American male. This is his first time coming for a clinical examination in one year. He reports having a reasonably healthy life until the last two months when he started gaining weight uncontrollably. He reports remaining active and practicing yoga in vain. He also reports having constipation and fatigue most of the days. “At first, I thought constipation and fatigue would end, but they don’t.” The client also reports that I eat well. I am worried about my health.” The patient reports experiencing aggravating joint pains, usually around the knees and elbows, usually at night, but also affecting his movement. He relieves the pain by taking acetaminophen1300 mg PO q8hr PRN. However, the pain keeps coming back over and over again.
Past Medical History: Allergies: medications, food, environmental or seasonalChildhood Illnesses: Adult Illnesses Injuries Surgeries Hospitalizations Obstetric/Gynecologic Psychiatric   Health Maintenance Immunization status: DPT, MMR, influenza, hepatitis, polio, Pneumovax, herpes zoster Dental exams (frequency and treatment) Last eye exam (include results) SBE/Pap/GYN (include results) Testicular/rectal exam (include results)  No known medication, environmental or food allergies Reports chicken pox – resolved on its own. Hypertension – Diagnosed in 2017. Well-controlled with medication. Type 2 Diabetes – Diagnosed in 2017. Well-controlled with medication. Last hemoglobin A1c was 6.9% 3 months ago. No history of injuries, surgeries, or hospitalization. Last dental exam – Every six months. Received all immunizations Eye exam – 2 weeks ago. MRD1 6mm. Exophthalmometer reading, 24. Current medication: Hydrochlorothiazide – 20 mg PO QD hypertension. No previous testicular/rectal exam. Lisinopril – 40 mg PO QD hypertension. Metformin – 1000 mg PO BID for diabetes.  
Family History: Include the presence or absence of specific illnesses in the family such as hypertension, diabetes, or cancerParents deceased. Paternal and maternal grandparents deceased. Father died at age 80 from Covid-19 complications and had type 2 diabetes. Mother died at age 65 in a road accident. Mother had type 2 diabetes and hypertension. Has a living sister aged 45, diagnosed with hypothyroidism and hypertension. Paternal grandfather died aged 88 from old age. Paternal grandmother died aged 85 from a myocardial infarction. Maternal grandfather died aged 87 from diabetes complications. Maternal grandmother died, aged 65, from breast cancer.
Personal and Social History: Educational levelPersonal interestsLifestyle: exercise and dietOlder Adults: ADLs and iADLs  Bachelor’s Degree Democratic politics Practices yoga. Healthy diet. None – Care for by the house help.
Review of Systems:  General   EyesEars/Nose/Throat       EndocrineCardiovascularRespiratoryGastrointestinal   Genitourinary     Hematology/Lymph       IntegumentaryNeckNeurological   MusculoskeletalPsychological  15lbs weight gain. Reports fatigue and weakness. Denies fever. Reports eye pain. Wears reading glasses.  Ears: No hearing loss or discharge. Nose: No epistaxis or nasal congestion. Throat: Dental exam six months ago. No throat pain. As per HPI and PMH. No chest discomfort or palpitations. No wheeze, cough, or sputum. No pain with breath. Report constipation, abdominal pain, and diarrhea. Urinary frequency and nocturia in the past three months, four times per night. No urination pain. No erection in the past year. No easy bruising or bleeding. No history of blood clots. Coarse, scale, and dry skin. Neck stiffness and pain. No swollen glands. No headaches or vertigo. Reports focal weakness and gait instability. As per HPI. Reports anxiety. No depression or suicide ideation.
Objective
Vital Signs and Measurements Blood pressureTemperaturePulseRespirationsHeightWeightBMI includes normal, overweight, obese, morbidly obese  116/100 mmHg 98.7F 79 bpm 15 breaths /min 5’7’’ 180 lbs. 28.2 kg/m2, overweight.
Physical Examination GeneralEyesEars/Nose/Throat                         Neck       Endocrine   Cardiovascular       Respiratory     Gastrointestinal   Genitourinary     Hematology/Lymph     IntegumentaryNeurological   Musculoskeletal   Psychological  Well-developed African American male of the stated age. Alert and oriented in all spheres. Vital signs as per the measurements. The Head is normocephalic. No scalp. Facial tenderness and pink conjunctivae. Present bilateral arcus senilis. Eyes: Eyelid appears retracted, pupils equal in size. Sharp disc margins. Present venous/arteriole nicking. No eye exudates or hemorrhages were seen. Ears: Hearing is grossly intact. Moderate cerumen. Intact tympanic membrane. No erythema. Nose: Minimal septal deviation. Throat: No lesions or exudates. Palpable thyroid. Midline trachea. Distention of the jugular venous present, 8.5cm. No meningismus. Strong carotid upstrokes. No bruits. Cold intolerance, polyuria, and polydipsia are observable. Intercostal space, 4.3cm laterally from the midclavicular line. Symmetric thoracic expansion, dullness of both assess and bases.   Regular rhythm and rate. S1 and S2 are normal physiologically. S3 is present, S4 absent.   There is no observable respiratory distress. Remarkable breath sounds. No, wheezes or stridor. No tactile fremitus or bronchophony. Abdomen is non distended. No tenderness. hyopactive bowel sounds. No palpable masses. No lesions in the genital area. No inguinal hernia. Moderately enlarged rectum, symmetric, no nodule, and nontender. Cervical or axillary lymph nodes absent. Palpable lymph nodes. Present inguinal nodes, small and mobile, about 4.5mm in size. Coarse, scaly, and dry skin. Focal weakness and gait instability.   Joint pain. No hand or bilateral knee deformities. Normal figure curls and movement. Strong muscles. Reduced range of motion. Appears anxious and lethargic.
Assessment and Plan: based on current literature/guidelines. This should be organized and succinct.Assessment Based on subjective and objective data, including constipation, lid extraction, lethargy, weight gain, coarse, scaly, dry skin, cold intolerance, and palpable goiter, the patient is likely to suffer from hypothyroidism.   Also known as Hashimoto, autoimmune thyroid disease is coded as E06.3. Autoimmune thyroid disease is characterized by cold sensitivity, constipation, skin dryness and roughness, weight gain, fatigue, sexual dysfunction, and lid extraction (Arcangelo et al., 2017). The patient presents all these symptoms. The condition is caused by increased thyroid-stimulating hormone (TSH), free thyroxine (FT4), and reduced circulating free triiodothyronine (FT3) (Calsolaro et al., 2019). As a result, the fibrosis increases, and thyroid function decreases.   Diagnostic Tests TSH (Thyroid-stimulating hormone) Test – Obtain a blood sample using a needle from the arm into a test tube. Normal TSH values are from 0.4 to 4.0 mIU/   Treatment Plan Start a partial replacement Levothyroxine Therapy with 0.8 mcg/kg of L-T4 with gradual increment using serum thyrotropin Levothyroxine is a standard therapy for hypothyroidism and is effective in resolving hypothyroidism symptoms (Jonklaas et al., 2014). Levothyroxine therapy is easily administered, has favourable side effects, long-term benefits, it is easily absorbed in the intestine, and has a long half-life.   2.    Cardiac – Perform complete blood count and metabolic panel. Obtain chest radiograph. Start diuresis – Use furosemide, 40 mg IV at 12 hrs interval. Monitor weight. Liquid intake/urine output. 3.    Ophthalmology: Begin eye drops to prevent glaucoma. 4.    Maintain insulin for diabetes control and acetaminophen joint pain. 5.    Health maintenance: Cancer screening up to date. Discuss appropriate dieting.    
Differential diagnoses, including ICD – 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings; articulate a rationale for the most likely diagnosis and each differential diagnosis. In this discussion, include pertinent positives and negatives, which help rule out or rule in each diagnosis.Hypothyroidism – Hypothyroidism is characterized by cold sensitivity, constipation, skin dryness and roughness, weight gain, fatigue, sexual dysfunction, and lid extraction as presented by the patient (Arcangelo et al., 2017). This is the primary diagnosis.Congestive Heart Failure (CHF), ICD-10 Code 150.22. The essential diagnostic features of congestive heart failure presented by the patient include jugular venous distention, weight gain, and a history of hypertension (Ball et al., 2021). However, the client does not present other significant CHF diagnostic features including peripheral edema, pitting edema, ascites, or hepatomegaly. Therefore, this diagnosis is refuted. Unspecified Kidney Failure, ICD-10 Code N19. Kidney failure is a condition in which both kidneys fails to function temporarily and sometime can be chronic. The essential features of kidney failure presented by the patient include fatigue, polyuria, and dry/itchy skill (Chen et al., 2019). However, the client does not present swollen necks or ankles, muscle spasms, or poor appetite from considering the subjective and objective data obtained. Therefore, this diagnosis is refuted.
Most likely diagnosis: (if more than one diagnosis, number each in order of priority) Include: Pathophysiology of the problemExplanation of the diagnosisDiagnostic TestingLab testingRadiology testingCardiac or Neurologic testingEvaluations – Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health EvaluationsMedications and Treatments – pharmacological and non-pharmacological treatments. Should include at least two evidence-based referencesMotivational InterviewingHypothyroidism The probable etiology of the patient’s condition is autoimmune thyroid disease/disorder. Autoimmune disorders attack body tissues (Calsolaro et al., 2019).   Lab testing – Obtain blood sample using a needle from the arm into a test tube. Normal TSH normal values are from 0.4 to 4.0 mIU/L. TSH values above the normal range justify the diagnosis.     Ultrasound – I recommend thyroid ultrasound to observe nodules usually present among patients diagnosed with hypothyroidism.   Refer to an endocrinologist – For monitoring and management of hypothyroidism.  
References (APA 7th format)Arcangelo, V. P., Peterson, A. M., Wilbur, V., Reinhold, J. A.  (2016). Pharmacotherapeutics for Advanced Practice, 4th Edition, Wolters Kluwer Health. Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2021). Seidel’s Guide to Physical Examination-E-Book: An Interprofessional Approach. Elsevier Health Sciences. Calsolaro, V., Niccolai, F., Pasqualetti, G., Tognini, S., Magno, S., Riccioni, T., … & Monzani, F. (2019). Hypothyroidism is the elderly: who should be treated and how?. Journal of the Endocrine Society, 3(1), 146-158. https://doi.org/10.1210/js.2018-00207 Mathew, P., & Rawla, P. (2022). Hyperthyroidism. StatPearls [Internet]. https://pubmed.ncbi.nlm.nih.gov/30725738/  
Hypothyroidism soap note example

Hypothyroidism SOAP Note Structure

The SOAP note structure consists of four main sections:

  1. Subjective: This section includes the patient’s reported symptoms, concerns, and any relevant information from their medical history. For hypothyroidism, this might include complaints of fatigue, weight gain, or cold intolerance.
  2. Objective: Here, the healthcare provider records measurable and observable data, such as vital signs, physical examination findings, and laboratory results. In hypothyroidism, this would typically include TSH levels, thyroid hormone levels, and any visible signs of thyroid enlargement or goiter.
  3. Assessment: This section contains the healthcare provider’s analysis of the patient’s condition based on the subjective and objective information. It includes the diagnosis, potential differential diagnoses, and any other relevant clinical impressions.
  4. Plan: The final section outlines the treatment strategy, including medications, lifestyle modifications, follow-up appointments, and any additional tests or referrals needed.

Key Components of a Hypothyroidism SOAP Note

When creating a SOAP note for hypothyroidism, several key components should be included:

  1. Detailed symptom description
  2. Thyroid function test results (TSH, T3, T4)
  3. Physical examination findings, including thyroid gland assessment
  4. Medication history and current thyroid hormone replacement therapy
  5. Comorbidities and their potential impact on thyroid function
  6. Patient’s response to treatment and any side effects
  7. Plan for dose adjustments and follow-up monitoring

How to Document Hypothyroidism in a SOAP Note?

Collecting Relevant Medical History

When documenting hypothyroidism in a SOAP note, it’s essential to gather a comprehensive medical history. This includes:

  1. Duration and onset of symptoms
  2. Family history of thyroid disorders
  3. Previous thyroid function tests and treatments
  4. Presence of autoimmune conditions (e.g., Hashimoto’s thyroiditis)
  5. Medications that may affect thyroid function
  6. Recent life changes or stressors that could impact thyroid health

Writing the Subjective and Objective Sections

Subjective Section: In this section, document the patient’s reported symptoms and concerns. For hypothyroidism, common complaints may include:

  • Fatigue and weakness
  • Weight gain or difficulty losing weight
  • Cold intolerance
  • Dry skin and hair
  • Constipation
  • Menstrual irregularities (in women)
  • Mood changes or depression

Example: “52-year-old white female presents with complaints of persistent fatigue, gradual weight gain (10 lbs over the past 6 months), and increased sensitivity to cold. Patient reports feeling tired throughout the day despite adequate sleep. She also notes dry skin and occasional constipation. Last menstrual period was 3 weeks ago, with cycles becoming irregular over the past year.”

Objective Section: Record measurable data and physical examination findings:

  • Vital signs (BP, heart rate, temperature)
  • Weight and BMI
  • Thyroid gland examination (size, consistency, presence of nodules)
  • Skin assessment (texture, moisture)
  • Reflexes (particularly deep tendon reflexes)
  • Recent laboratory results (TSH, free T4, T3)

Example: “Vital Signs: BP 128/82, HR 62, Temp 97.8°F Weight: 165 lbs, BMI 27.5 Physical Exam: Mild goiter with right side of thyroid gland slightly larger than the left. No palpable nodules. Skin appears dry. Deep tendon reflexes slightly delayed. Labs (drawn 2 days ago): TSH 8.5 mIU/L (elevated), Free T4 0.7 ng/dL (low normal)”

Assessing Signs and Symptoms of Hypothyroidism

When assessing signs and symptoms of hypothyroidism, it’s important to consider both the common and less frequent manifestations of the condition. This comprehensive approach helps in accurate diagnosis and appropriate management.

Common signs and symptoms to assess include:

  1. Fatigue and decreased energy levels
  2. Weight gain or difficulty losing weight
  3. Cold intolerance
  4. Dry, coarse skin
  5. Hair thinning or loss
  6. Constipation
  7. Muscle weakness or cramps
  8. Joint pain or stiffness
  9. Depression or mood changes
  10. Menstrual irregularities in women
  11. Decreased libido
  12. Slow heart rate (bradycardia)
  13. Mild cognitive impairment or “brain fog”

Less common but significant signs to consider:

  1. Goiter (enlarged thyroid gland)
  2. Hoarseness of voice
  3. Periorbital edema (puffy eyes)
  4. Carpal tunnel syndrome
  5. Sleep apnea
  6. Myxedema (severe form of hypothyroidism)

What Should Be Included in the Assessment Section?

The assessment section of a SOAP note for hypothyroidism should provide a comprehensive analysis of the patient’s condition based on the subjective and objective information gathered. It should include:

Evaluating TSH Levels and Their Significance

TSH (Thyroid Stimulating Hormone) is the primary screening test for thyroid dysfunction. In the assessment section, interpret the TSH levels and their significance:

  • Normal TSH range: Generally between 0.4 to 4.0 mIU/L (may vary slightly by laboratory)
  • Elevated TSH (>4.0 mIU/L): Suggests primary hypothyroidism
  • Highly elevated TSH (>10 mIU/L): Strong indication of overt hypothyroidism
  • Mildly elevated TSH (4.0-10 mIU/L): May indicate subclinical hypothyroidism

Example: “TSH level of 8.5 mIU/L indicates primary hypothyroidism. This, combined with the low-normal free T4 level and the patient’s symptoms, supports the diagnosis of overt hypothyroidism.”

Identifying Differential Diagnoses

While the clinical picture may strongly suggest hypothyroidism, it’s important to consider other conditions that may present with similar symptoms:

  1. Anemia
  2. Depression
  3. Chronic fatigue syndrome
  4. Fibromyalgia
  5. Sleep disorders
  6. Vitamin D deficiency
  7. Adrenal insufficiency

Example: “While the clinical presentation and laboratory findings are consistent with primary hypothyroidism, other conditions such as anemia and depression have been considered and will be ruled out through additional testing if symptoms persist despite thyroid hormone replacement.”

Documenting Patient’s Vital Signs (e.g., BP)

Include an interpretation of the patient’s vital signs, particularly blood pressure, as hypothyroidism can affect cardiovascular function:

  • Normal or slightly elevated blood pressure is common in hypothyroidism
  • Bradycardia (slow heart rate) may be present
  • Body temperature may be slightly lower than normal

Example: “Patient’s BP of 128/82 is within normal range. Heart rate of 62 bpm is on the lower end of normal, which is consistent with hypothyroidism. Slightly low body temperature (97.8°F) also aligns with thyroid hormone deficiency.”

How to Create an Effective Plan Section?

The plan section of a SOAP note for hypothyroidism should outline a comprehensive strategy for managing the patient’s condition. It should include:

Strategies for Patient Care in Hypothyroidism

  1. Thyroid Hormone Replacement Therapy:
    • Specify the type of medication (e.g., levothyroxine)
    • Indicate the starting dose and schedule for dose adjustments
    • Provide instructions for medication administration (e.g., take on an empty stomach)
  2. Additional Testing:
    • Order follow-up thyroid function tests (TSH, free T4) to monitor treatment response
    • Consider testing for thyroid antibodies to determine if Hashimoto’s thyroiditis is the underlying cause
    • Recommend lipid panel and other relevant tests to assess comorbidities
  3. Lifestyle Modifications:
    • Dietary recommendations (e.g., adequate iodine intake, balanced nutrition)
    • Exercise guidelines to support weight management and overall health
    • Stress reduction techniques

Example: “1. Initiate levothyroxine 50 mcg daily, to be taken on an empty stomach 30-60 minutes before breakfast. 2. Repeat TSH and free T4 in 6-8 weeks to assess response to treatment. 3. Order thyroid peroxidase (TPO) antibodies to evaluate for Hashimoto’s thyroiditis. 4. Recommend a balanced diet rich in fruits, vegetables, and lean proteins. Encourage moderate exercise for 30 minutes, 5 days a week.”

Setting Goals for Weight Management and Relaxation

Incorporate specific, achievable goals related to weight management and stress reduction:

  1. Weight Management:
    • Set a realistic weight loss target (e.g., 1-2 lbs per month)
    • Recommend keeping a food diary
    • Consider referral to a nutritionist if needed
  2. Relaxation Techniques:
    • Suggest practicing mindfulness or meditation for 10-15 minutes daily
    • Recommend yoga or gentle stretching exercises
    • Encourage adequate sleep hygiene

Example: “Goals:

  1. Aim for gradual weight loss of 1-2 lbs per month through diet and exercise.
  2. Practice a relaxation technique of choice (e.g., deep breathing, meditation) for 10 minutes daily to manage stress.
  3. Establish a consistent sleep schedule, aiming for 7-8 hours of sleep per night.”

Follow-Up and Monitoring Recommendations

Outline a clear follow-up plan to ensure proper monitoring of the patient’s condition:

  1. Schedule a follow-up appointment in 6-8 weeks to review thyroid function tests and assess symptom improvement
  2. Plan for regular TSH monitoring every 6-12 months once stable on replacement therapy
  3. Recommend annual physical examinations to assess overall health and screen for potential complications

Example: “Follow-up:

  1. Schedule appointment in 8 weeks with repeat TSH and free T4 tests 1 week prior.
  2. If stable on current dose, plan for TSH monitoring every 6 months for the first year, then annually.
  3. Encourage patient to report any new or worsening symptoms promptly.
  4. Schedule annual physical examination to assess overall health status.”

What Are the Common Signs and Symptoms of Hypothyroidism?

Hypothyroidism can affect multiple body systems, leading to a wide range of signs and symptoms. Understanding these manifestations is crucial for accurate diagnosis and effective management.

Recognizing Physical Symptoms: Goiter and Weight Gain

Goiter: A goiter is an enlargement of the thyroid gland that can occur in hypothyroidism, often due to the body’s attempt to produce more thyroid hormone. Key points about goiter in hypothyroidism include:

  • May be visible or palpable in the neck
  • Can be diffuse or nodular
  • May cause discomfort or difficulty swallowing in some cases
  • Not always present in hypothyroidism, especially in iodine-sufficient areas

Weight Gain: Weight gain is a common and often distressing symptom of hypothyroidism. Important aspects include:

  • Typically gradual and persistent
  • Often resistant to diet and exercise efforts
  • May be accompanied by fluid retention and bloating
  • Can contribute to decreased self-esteem and body image issues

Other Physical Symptoms:

  • Dry, coarse skin
  • Hair thinning or loss
  • Brittle nails
  • Constipation
  • Muscle weakness and joint pain
  • Puffy face, especially around the eyes
  • Hoarseness of voice
  • Slow heart rate (bradycardia)
  • Elevated blood pressure (in some cases)

Understanding Mental Health Impacts

Hypothyroidism can significantly affect mental health and cognitive function. Common psychological and cognitive symptoms include:

  1. Depression:
    • Persistent low mood
    • Loss of interest in activities
    • Feelings of worthlessness or guilt
  2. Anxiety:
    • Increased worry or nervousness
    • Difficulty relaxing
    • Physical symptoms such as rapid heartbeat or sweating
  3. Cognitive Issues:
    • Difficulty concentrating or “brain fog”
    • Memory problems
    • Slowed thinking and processing speed
  4. Fatigue and Lethargy:
    • Persistent tiredness
    • Lack of energy
    • Increased need for sleep
  5. Mood Swings:
    • Irritability
    • Emotional lability

It’s important to note that these mental health impacts can significantly affect a patient’s quality of life and may persist even after thyroid hormone levels are normalized with treatment.

Patient Demographics: Old White Female Considerations

When addressing hypothyroidism in older white female patients, several demographic-specific considerations should be taken into account:

  1. Increased Prevalence:
    • Hypothyroidism is more common in women, especially those over 60 years old
    • The risk increases with age
  2. Menopausal Symptoms:
    • Hypothyroidism symptoms may overlap with menopausal symptoms, complicating diagnosis
    • Important to differentiate between thyroid dysfunction and normal menopausal changes
  3. Osteoporosis Risk:
    • Both age and hypothyroidism can increase the risk of osteoporosis
    • Careful monitoring of bone density may be necessary, especially if thyroid hormone replacement is required
  4. Cardiovascular Considerations:
    • Older patients may have pre-existing cardiovascular conditions
    • Hypothyroidism can exacerbate cardiovascular risks
  5. Medication Interactions:
    • Older patients are more likely to be on multiple medications
    • Careful consideration of potential drug interactions with thyroid hormone replacement is crucial
  6. Cognitive Function:
    • Hypothyroidism can exacerbate age-related cognitive decline
    • Prompt treatment may help maintain cognitive function
  7. Atypical Presentation:
    • Older patients may present with fewer classical symptoms of hypothyroidism
    • “Apathetic hyperthyroidism” may occur, where patients exhibit mainly fatigue and depression

Example: “72-year-old white female presenting with fatigue, mild weight gain, and cognitive complaints. Given her age and demographic, consider thyroid function testing to differentiate between normal aging, menopausal symptoms, and potential hypothyroidism. Assess cardiovascular risk factors and current medications for potential interactions with thyroid management.”

Case Studies and Examples

Case Study 1: Newly Diagnosed Hypothyroidism

Patient: 45-year-old white female presenting with fatigue, weight gain, and cold intolerance.

SOAP Note incorporating CIM:

S (Subjective):

  • Chief Complaint: Fatigue (SNOMED CT: 84229001)
  • Associated Symptoms:
    • Weight gain (SNOMED CT: 8943002)
    • Cold intolerance (SNOMED CT: 13791008)
  • Symptom Duration: 6 months
  • Review of Systems: Negative for palpitations, heat intolerance, or tremors

O (Objective):

  • Vital Signs:
    • BP: 128/82 mmHg
    • HR: 62 bpm
    • Temp: 97.8°F
    • Weight: 165 lbs (BMI: 27.5)
  • Physical Examination:
    • Thyroid: Mild diffuse enlargement (SNOMED CT: 271427001)
    • Skin: Dry (SNOMED CT: 39857003)
    • Reflexes: Delayed relaxation phase (SNOMED CT: 271602006)
  • Laboratory Results:
    • TSH: 8.5 mIU/L (Reference: 0.4-4.0)
    • Free T4: 0.7 ng/dL (Reference: 0.8-1.8)

A (Assessment):

  • Primary Diagnosis: Primary hypothyroidism (ICD-10: E03.9)
  • Severity: Moderate (based on TSH level and symptoms)
  • Differential Diagnoses:
    1. Hashimoto’s thyroiditis (ICD-10: E06.3)
    2. Subclinical hypothyroidism (ICD-10: E02)

P (Plan):

  1. Treatment:
    • Initiate levothyroxine 50 mcg daily (RxNorm: 966222)
  2. Monitoring:
    • Repeat TSH and Free T4 in 6-8 weeks (LOINC: 3016-3, 3024-7)
  3. Diagnostics:
    • Order thyroid peroxidase (TPO) antibodies (LOINC: 8480-6)
  4. Patient Education:
    • Provide information on hypothyroidism (SNOMED CT: 722447001)
    • Discuss medication administration and potential side effects
  5. Follow-up:
    • Schedule appointment in 8 weeks

Case Study 2: Long-term Management of Hypothyroidism

Patient: 62-year-old white female with well-controlled hypothyroidism on levothyroxine for 5 years.

SOAP Note incorporating CIM:

S (Subjective):

  • Current Status: Reports feeling well, no new symptoms
  • Medication Adherence: Takes levothyroxine 100 mcg daily as prescribed
  • Review of Systems: Negative for fatigue, weight changes, or mood disturbances

O (Objective):

  • Vital Signs:
    • BP: 122/76 mmHg
    • HR: 68 bpm
    • Temp: 98.2°F
    • Weight: 150 lbs (BMI: 25.1)
  • Physical Examination:
    • Thyroid: No palpable enlargement (SNOMED CT: 248528008)
    • Skin: Normal texture and moisture
    • Reflexes: Normal (SNOMED CT: 162737005)
  • Laboratory Results:
    • TSH: 2.1 mIU/L (Reference: 0.4-4.0)
    • Free T4: 1.2 ng/dL (Reference: 0.8-1.8)

A (Assessment):

  • Primary Diagnosis: Hypothyroidism, well-controlled on treatment (ICD-10: E03.9)
  • Thyroid Function: Stable and within target range
  • Overall Health Status: Good

P (Plan):

  1. Continue current treatment:
    • Levothyroxine 100 mcg daily (RxNorm: 966227)
  2. Monitoring:
    • Annual TSH and Free T4 testing (LOINC: 3016-3, 3024-7)
  3. Preventive Care:
    • Recommend age-appropriate cancer screenings
    • Assess bone health and consider DEXA scan
  4. Patient Education:
    • Review signs of over- or under-treatment
    • Discuss importance of medication adherence
  5. Follow-up:
    • Schedule annual follow-up appointment

Related Article

https://www.ncbi.nlm.nih.gov/books/NBK482263

FAQs

  1. What is the clinical approach to hypothyroidism?
  • Thorough history taking and physical examination
  • Thyroid function tests (TSH, free T4)
  • Initiation of thyroid hormone replacement therapy (usually levothyroxine)
  • Regular monitoring and dose adjustments
  • Patient education on medication adherence and symptom management
  • Long-term follow-up to ensure optimal thyroid function
  1. What is the clinical evaluation of hypothyroidism?
  • Assessing symptoms (fatigue, weight gain, cold intolerance, etc.)
  • Physical examination (thyroid gland palpation, skin texture, reflexes)
  • Laboratory tests (TSH, free T4, sometimes T3)
  • Evaluation of potential complications (cardiovascular, metabolic)
  • Consideration of underlying causes (e.g., Hashimoto’s thyroiditis)
  1. How do you write soap format?

SOAP format is written as follows: S – Subjective: Patient’s symptoms, concerns, and history O – Objective: Physical examination findings and test results A – Assessment: Diagnosis, differential diagnoses, and clinical reasoning P – Plan: Treatment strategy, follow-up, and patient education

  1. Which part of the SOAP note contains clinical evidence?

The Objective (O) section of the SOAP note primarily contains clinical evidence, including:

  • Vital signs
  • Physical examination findings
  • Laboratory and imaging results
  • Other measurable data relevant to the patient’s condition

However, clinical evidence can also be found in other sections:

  • Subjective (S): Patient-reported symptoms and history
  • Assessment (A): Interpretation of clinical findings
  • Plan (P): Evidence-based treatment decisions
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