Prompt No.

1:
A 40-year-old housewife complains of progressive weight gain of 20 pounds over the last year,
fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin,
constipation, and cold intolerance. She claims her menses have been irregular in the last year.
She has an 18-year-old daughter and has been trying to have another child with her new partner
but has been unsuccessful.

INTRODUCTION

Hypothyroidism occurs when the thyroid gland produces insufficient thyroid hormones or
when the hypothalamus or pituitary gland stimulates the thyroid gland insufficiently (Wilson
et.al, 2021). The thyroid is a butterfly-shaped endocrine gland at the lower front of the neck. This
produces thyroid hormones, which are subsequently released into the bloodstream and delivered
to all of the body's tissues. Thyroid hormone aids in the efficient use of energy, the maintenance
of body temperature, and the proper functioning of the brain, heart, muscles, and other organs
(American Thyroid Association [ATA], 2022).

According to data from the National Health and Nutrition Examination Survey,
approximately one in every 300 people in the United States has hypothyroidism. The incidence
rises with age and is greater in women than in men (Gaitonde et.al, 2012).

Iodine deficiency, as coupled with endemic goiter, is the most prevalent cause of
hypothyroidism globally. In contrast, a study of Chinese patients found a substantial rise in overt
hypothyroidism in those who consumed too much iodine. The most common causes of
hypothyroidism in the United States and industrialized countries are autoimmune destruction of
the thyroid gland and iatrogenic due to Graves’ disease medication. Primary hypothyroidism, the
dysfunction of the thyroid gland, accounts for up to 90% to 95% of cases. The majority of the
remaining cases has secondary hypothyroidism, caused by pituitary or hypothalamic dysfunction
(Schraga, 2020).
 Hypothyroidism is diagnosed based on symptoms and the results of blood tests that
quantify the thyroid-stimulating hormone (TSH) and, in certain cases, thyroid hormone thyroxine
levels. Thyroid underactivity is indicated by a low thyroxine level and a high TSH level. The
synthetic thyroid hormone levothyroxine is used on a regular basis to treat hypothyroidism. This
oral drug restores appropriate hormone levels, correcting hypothyroidism's indications and
symptoms (Mayo Foundation for Medical Education and Research, 2020).

PATIENT’S GENERAL INFORMATION

Age: 40 years old

Gender: Female
Occupation: Housewife

Chief Complaint:
The patient complains of progressive weight gain of 20 pounds over the last year, fatigue,
postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation,
and cold intolerance.

Present Health History:

The patient presented to the clinic looking tired and weak. She verbalized feeling fatigue
most of the time over the last year. She has gained weight and was feeling cold all the time. She
also reported non-spinning dizziness and unsteadiness when standing or walking, loss of
memory, slow speech, deepening of her voice, dry skin, and constipation.

Past Health History:

The patient has no chronic illnesses and no surgical history.

Family History:
The patient has an 18-year-old daughter who’s in good health condition. They’re living
with her new partner.
Social History:
The patient devotes all her time, energy and love into creating a safe, warm, clean home for
her family to grow and thrive.

SOAP NOTE

Subjective Data

The healthcare provider must perform a full history evaluation of the patient to identify
factors supporting hypothyroidism as the main diagnosis. Obtain patient’s health history to
include any autoimmune disorders such as Hashimoto's disease, genetic problems, or an
insufficient consumption of iodine-rich foods. In addition, see if she is on any medication that
might produce hypothyroidism as a side effect such as Amiodarone, or if she is undergoing neck
radiation or surgery for cancer treatment.

Review of Systems (14 Systems recognized by the Centers for Medicare and Medicaid Services):
Constitutional Symptoms:
The patient reports weight gain and has been feeling fatigue over the last year.

Eyes:
The patient denies blurring of vision or any eye discomfort.

Ears, Nose, Mouth, Throat:

The patient states that she has no any ear problems such as hearing loss, tinnitus, and ear
pain. She also denies any conditions involving the nose such as loss or diminished sense of
smell, nasal congestion, and nosebleeds. She has no pain and difficulty swallowing as well.
However, she experiences progressive postural dizziness, slowing of speech and deepening of
her voice over the last year.
Cardiovascular:
The patient denies chest pain, palpitations, irregular heartbeats, and slowing or rapid
pulses. She states experiencing postural dizziness.

Respiratory:
The patient denies coughing, irregular breathing pattern or difficulty breathing.

Gastrointestinal:
The patient states that she has good appetite but states that she experiences constipation.

Genitourinary:
The patient denies urinary urgency, nocturia, hematuria, and burning urination. She has
irregular menses in the last year.

Musculoskeletal:
The patient denies any muscle pain or stiffness, joint pain, and back pain.

Integumentary:
The patient states drying of skin but denies pruritus.

Neurological:
The patient states that she experiences memory loss. She denies having tremors or
seizures and sensorimotor deficits.

Psychiatric:
The patient denies experiencing hallucinations, anxiety and depressive mood.

Endocrine:
 The patient reports cold intolerance. She has experienced irregular menstrual cycle in the
last year and is trying to have another child with her new partner but has been unsuccessful
(infertility).

Hematologic/Lymphatic:
The patient denies history of bleeding or surgeries involving the lymphatic system such
as tonsillectomy and splenectomy.

Allergic/Immunologic:
The patient denies having allergies to food and drugs.

Objective Data

Hypothyroidism is diagnosed based on symptoms, imaging tests such as CT scan and

sonography, and blood tests to assess TSH and the thyroid hormone levels.

Review of Systems (14 Systems recognized by the Centers for Medicare and Medicaid Services):
Constitutional Symptoms:
The patient’s vital signs are as follows: Temp= 98.6°C, PR= 68 bpm, RR= 17 bpm, BP=
120/80 mmHg, SpO2= 98% on room air. The patient weighs 160 pounds and 5’3” tall, with a
body mass index (BMI) of 28, indicating that her weight is in the overweight category for adults
of her height.

Eyes:
The patient has no eye redness, irritation, and scleral icterus. There’s no strabismus or
nystagmus. Both pupils are equal, round, and reactive to light and accommodation.

Ears, Nose, Mouth, Throat:

The patient has puffy facial appearance. She has no palpable lumps or masses in the
auricle of the ear, with patent ear canal and pearly grey tympanic membrane. Her nose is
symmetrical with no discoloration or swelling. Nasal mucosa is pinkish red with no discharges,
bleeding, and swelling. The patient’s lips are also symmetrical, pink, and smooth. The oral
mucosa and gums are moist and pink with normal dentition. The trachea is in the midline, the
lymph nodes are not palpable but the thyroid gland is mildly swollen but it is not tender. Her
voice was low and hoarse.

Cardiovascular:
The patient’s jugular vein is not distended. Her heart rate upon examination is 68 beats
per minute with a regular rhythm; S1-S2 present, not diminished or accentuated, no S3 or S4,
and no murmurs. Peripheral pulses were palpable and +2 with a normal capillary refill.

Respiratory:
Patient’s chest moves symmetrical with respiration and has clear breath sounds on
auscultation.

Gastrointestinal:
The patient has palpable lumpy mass in the left abdominal quadrant pertinent to
constipation, which are also dull to percussion with decreased bowel sounds.

Genitourinary:
The patient’s urinary bladder is not palpable, no suprapubic tenderness. She’s not
menstruating on the day of assessment and has no unusual vaginal discharges.

Musculoskeletal:
The patient does not have atrophied muscles or joint dislocations. Full range of motion
seen in both upper and lower extremities.

Integumentary:
The patient’s skin is warm, no peripheral cyanosis, and it is dry.

Neurological:
 Upon assessment, the patient was alert and oriented to person, place, and time. All cranial
nerves were grossly intact and her reflexes were normal with normal muscle tone.

Psychiatric:
The patient was cooperative and has appropriate mood and affect during the assessment.

Endocrine:
The patient presents to the clinic looking tired and weak. She has a puffy face and
enlarged thyroid gland.

Hematologic/Lymphatic:
The patient has pink, symmetrical and normal-size tonsils. Her lymph nodes are palpable
but not painful, swollen or enlarged.

Allergic/Immunologic:
The patient has no visible skin rash, swelling, or pain relevant to allergic reactions.

Diagnostic Tests:
According to Schübel and colleagues (2017), hypothyroidism diagnosis is grounded on
the presenting symptoms of the patient and laboratory tests including thyroid-stimulating
hormone test and thyroid function test.
 Thyroid-stimulating hormone assay is the most accurate screening tool for primary
hypothyroidism which tests the amount of T4 that the thyroid gland is being signaled to
produce. This test would be recommended to assist in the confirmation of the diagnosis of
hypothyroidism.
 Thyroid function test is a blood test that is used to measure the levels of thyroid hormones
free T4 (thyroxine), total T3 (triiodothyronine), and TSH (thyroid-stimulating hormone).
 Thyroid ultrasound scan can be used to determine if the thyroid has a nodule and infiltrative
disease and thus, I would recommend it for the patient.
 Assessment

Primary Diagnosis: Hypothyroidism

Hypothyroidism due to insufficient thyroid hormones produced by the thyroid gland or
neuroendocrine dysfunction. This condition slows down the metabolism causing the person to
feel tired, gain weight and be unable to tolerate cold temperatures (Wilson et.al, 2021).
Pertinent Positive: Significant weight gain, fatigue, lethargy, cold intolerance,
constipation, change in voice, dry skin, irregular menses, and
infertility.
Pertinent Negative: None present

Differential Diagnosis No. 1: Hypopituitarism

Hypopituitarism is an uncommon condition in which your pituitary gland fails to produce one or
more hormones or produces insufficient hormones (Mayo Foundation for Medical Education and
Research, 2021).
Pertinent Positive: Significant weight gain, fatigue, and sensitivity to cold.
Pertinent Negative: None present

Differential Diagnosis No. 2: Polycystic Ovary Syndrome (PCOS)

Women with PCOS frequently have hormonal imbalances and slow metabolism resulting to
weight gain. The hormonal imbalance interferes with menstrual cycle, leading to infertility
(Pathak, 2021).
Pertinent Positive: Significant weight gain, irregular menstruation, and infertility.
Pertinent Negative: None present

Plan
 Screening is important to identify the etiology of the disease, to include a history of
autoimmune disease, previous radiation treatment to the head or neck, family history of thyroid
problems, and use of medications known to affect thyroid function.

Treatment Plan:
 Thyroid hormone replacement therapy: Levothyroxine 50 mcg per day, to be taken on the
same time every day at least an hour before eating breakfast.
 Laxative: Bisacodyl (Dulcolax) 10mg/tab, one tablet orally daily at bedtime.

 Referral to a nutritionist-dietician for diet counselling.

Health Promotion:
 Instruct the patient to have a low-iodine diet. Eating low-iodine increases the effectiveness of
the treatment (Duntas, 2016).
 Encourage the patient to eat a high-fiber, low-calorie diet to relieve constipation and maintain
a healthy weight.
 In case of any adverse reactions to the drugs and she notices severe side effects (increased
anxiety, becomes very irritable, severe headaches and pounding heartbeat) the patient should
report this to the physician immediately.

Follow-Up:
 Instruct the patient to return four weeks after starting therapy to check symptom reduction or
the efficacy of hormone therapy.

REFERENCES

American Thyroid Association (2022). Hypothyroidism (Underactive).

https://www.thyroid.org/hypothyroidism/
Duntas, L. (2016). Subclinical Hypothyroidism: When Should We Start Treatment? Endocrine
Abstracts. https://doi.org/10.1530/endoabs.41.s11.3
Gaitonde, D.Y., Rowley, K.D., & Sweeney, L.B. (2012). Hypothyroidism: An Update. Retrieved
March 14, 2022, from https://www.aafp.org/afp/2012/0801/p244.html
Mayo Foundation for Medical Education and Research (2020, November). Hypothyroidism
(Underactive Thyroid): Diagnosis and Treatment. Retrieved March 15, 2022, from
https://www.mayoclinic.org/diseases-conditions/hypothyroidism/
Mayo Foundation for Medical Education and Research (2021, February). Hypopituitarism:
Symptoms and Causes. Retrieved March 15, 2022, from
https://www.mayoclinic.org/diseases-conditions/hypopituitarism/
Pathak, N. (2021, September). Polycystic Ovary Syndrome. Retrieved March 15, 2022, from
https://www.webmd.com/women/what-is-pcos
Schraga, E.D. (2020, March). What causes Hypothyroidism?
https://www.medscape.com/answers/768053-180937/what-causes-hypothyroidism
Schübel, J., Feldkamp, J. Bergmann, A., Drossard, W., & Voigt, K. (2017, June). Latent
Hypothyroidism in Adults. Deutsches Arzteblatt International, 114 (25): 430-438.
http://doi.org/10.3238/arztebl.2017.430
Wilson, S.A., Stem, L.A., & Bruehlman, R.D. (2021, May). Hypothyroidism: Diagnosis and
Treatment. Retrieved March 14, 2022, from
https://www.aafp.org/afp/2021/0515/p605.html