NU 650 Week 4 Assignment 1

Subjective

Patient Name: F W

Race/Ethnicity: Caucasian

DOB: 02/15/1979

Age: 44

Marital Status: Divorced

Chief Complaint (CC): “For the last three weeks, I have been feeling fatigued and very weak. My skin has also been feeling a bit dry despite continuous hydration. My hair has also deemed dry for some reason, and also, when brushed with a stiff brush, it comes off in smaller bits.”

History of Present Illness (HPI): F.W. has been experiencing persistent fatigue and general body weakness for the past three weeks. Despite maintaining adequate hydration and skin moisturization, the patient reports skin dryness. She also reported that her hair has been unusually dry and appears brittle, as evidenced by hair breakage when brushed with a stiff brush. These symptoms have been ongoing for approximately three weeks.

Review of Systems (ROS):

General: The patient denied any signs of weight gain or loss. During the same period, she has not experienced fever. However, she reports that she experiences fatigue and general body weakness.
Skin: The patient denies having eczema, rashes, or other skin abnormalities. However, her skin has felt very dry in the last three weeks.
Hair/Nails: The patient’s hair has also been unusually dry and brittle. No changes in the color of the nail, shape, or brittleness.
HEENT (Head, Eyes, Ears, Nose, Throat): Does not have a history of head injury. Not experienced any form of headache in the three weeks. Denies eye pain, drainage, and eye dryness. No problems with hearing or do not use hearing aids, discharge, or infections. She denies having nose bleeds, nasal congestion, or sinus problems. No problems with bleeding gums and dentures. Denies swallowing problems and sore throat.
Respiratory: Denies experiencing discomfort in the chest, shortness of breath, and wheezing chronic cough.
Cardiovascular: Neither hand nor foot neither swelling nor chest pain. Higher blood pressure is reported.
Peripheral Vascular: Denies having leg cramps, varicose veins, a history of blood clots, or feeling chilly or numb.
Musculoskeletal System: Reported muscle pain, back pain, and joint stiffness. No swelling to her joints, range of motion concerns and arthritis.
Neuro: Denies having a seizure, fainting, or experiencing tingling, numbness, or paralysis.
Gastrointestinal: Claims to have a good appetite. Denies having liver, gallbladder, or jaundice problems.
Urinary: F.W. denies feeling any of the following signs: hesitation burning, nocturia, polyuria, urgency, or frequency. She also says she doesn’t have any sores or leakage.
Hematologic: No record of Anemia, bleeding and bruises.
Endocrine: No records of diabetes, increased hunger, thirst and urination.

Past Medical History (PMH):

No record of a childhood illness. No records of hospitalizations or ER visits in the last 15 years.

Social History:

Marital Status: Divorced.

Living arrangement: F W stays with her elderly father and two of her daughters at their home.

Occupation: Works as a Departmental manager at one of the local dealerships for the past ten years.

Education: A Business Management university Degree.

Religion: Catholic.

Dietary habits: Eats well

Substance use:

Alcohol: consumes alcohol once in a while in her leisure time.

Smoking: Denies ever smoking in her entire life.

Past Surgical History:

In her entire life, she has undergone two essential surgeries. At 24, she gave birth to her first-born daughter through caecilian surgery. At 30, she gave birth to her second-born daughter, who was also born through a caecilian procedure.

Family History:

Siblings: She has no sibling’s alive to date. Her only brother died three years ago due to complications brought by COVID-19.

Children: She is the mother of two beautiful daughters. The first-born daughter is 20-year-old while her last born is 14 years old. All are of good health.

Parents:

Mother: The mother passed on at 58 after a long battle with cervical cancer. Her father is 69 and lives with her daughter as the primary care provider.

Medications:

She is currently taking Tylenol for her back pain.

Immunizations:

The immunization records are current. Her latest immunization was against pneumococcal disease and influenza.

Allergies:

Denies having allergy on latex, medicinal products, environment, food and herbal allergies.

Functional Assessment: Health Maintenance Practices

Activity/exercise:Strick’s gym routine entails two hours of vigorous aerobics and one hour of yoga meditation.
Sleep/rest:sleeps well through the night without disruptions, accumulation of approximately seven hours of deep sleep and rest
Nutrition/elimination:Eats a balance diet.
Relationships/resources:Healthy relationship with her ex-husband, with whom they co-parent their two beautiful daughters and a strong bond with her father and daughters.
Spirituality:Christian
Coping and stress management:She has a hectic work schedule and is also the primary caregiver of her aging father. Therefore, she reports experiencing mild stress. To cope with this stress, she has a strict schedule that entails both relaxation and meditation yoga, which greatly alleviates her stress.
Safety: Her home is her haven, together with her loved ones.
Screenings: The most recent screening took place a year ago. It dealt with breast and cervix cancer. In the past four years, she has also undergone a colonoscopy or another Pap smear examination.

Objective

General:
A Caucasian woman of 44 years old. Based on her outward appearance, she appears to be in no danger. She is alert, attentive, and cooperative and speaks in whole sentences without stuttering.
Vital Signs:
Temperature: 98.5°F, Blood Pressure: 123/54 mm Hg, Heart Rate: 70, Respiratory Rate: 22 breaths per minute, Oxygen Saturation: 97% on room air
Height: 66 inches Weight: 120 pounds BMI: 21
HEENT (Head, Eyes, Nose, Throat): Head: Normal-cephalic, with even hair growth, although it appears dry and brittle. Eyes: Sclera and conjunctiva are clear, PERRLA is intact, and EOMs are present. Ears: There is no discomfort and no change in the tympanic membranes. External ear infections, bumps, or discomfort are not present. The auricles are free of any abnormalities, malignancies, or lesions. Nose: The nose is in its normal pink color. Normal for the middle and inferior turbinate’s. There isn’t any obstruction. There are no sinus headaches. Both polyps and ulcers are absent. Olfactory function was normal; there was no pain in the frontal or maxillary sinuses. Mouth: Lips are red and moist, mucous membranes are moist, there is no cracking, thrush, vesicles, or lesions, and the dentition is in good health.
Lymph Nodes: There is no neck discomfort, nodules, goiter, torticollis, enlarged lymph nodes, or restricted range of motion.
Respiratory: The diaphragm rises and falls evenly, with 22 breaths each minute of effortless inhalation and expiration. The thorax displays excellent expansion and fremitus, with no sign of cyanosis. It is non-tender and maintains its symmetrical integrity. Percussion triggers the lungs’ proper response. Vesicular in nature, breath sounds lack rhonchi or crackles. Both diaphragms have decreased symmetrically by 3 cm, and no extraneous noises are present.
Cardiovascular: There are distinct S1 and S2 cardiac sounds but no S3. There are no bilateral basilar crackles, murmurs, pericardial rub, tachycardia, JVD, or peripheral edema.
Abdomen: The abdomen appears round and made of a malleable, soft material. Auscultation is used to determine whether there are bowel sounds in each of the four quadrants. Organomegaly or bruits are not detected.
Peripheral Vascular System: There are no edema, stasis, or varicosities, and the extremities are warm and symmetrical. The calf retains its original sensitivity and elasticity to a large extent. There are no discernible femoral or abdominal bruits. There is a palpable epitrochlear lymph node and a normal axilla. The brachial, dorsal Pedi’s, femoral, radial, popliteal, and posterior tibia arteries all exhibit bilateral symmetry and a muscle strength of 2+. The Allen arterial perfusion test revealed negative results.
Cranial nerves: All cranial nerves, from CNII to CNXII, are complete and operate within the normal range. Motor System: Muscle mass and tone are both within acceptable ranges. The bilateral strength remains unaltered. Both the right and left arms’ flexion and extension muscle strength are evaluated at 5/5, with no signs of deterioration. Coordination: There are no strange or erratic movements. The gait is constant, with regular steps, bases, arm swings, and turns, and the posture is standard. Both heel and toe walking are normal; neither is abnormal. Sensory: Normal touch and pinprick feeling are present in the fingers and toes.

Assessment

Hypothyroidism: Underactive thyroid, or hypothyroidism, is a disorder in which the thyroid gland does not generate enough thyroid hormones. This may result in a sluggish metabolism, resulting in signs and symptoms such as fatigue, dry skin, and brittle hair (Martin, 2022). TSH and free thyroxine (T4) levels are measured in blood tests to detect the presence of hypothyroidism in an individual. Thyroid hormone medication is often taken to restore normal thyroid hormone levels and treat symptoms. Through routine examinations, the doctor can establish the proper dosage of this medication (Hypothyroidism (Underactive Thyroid) – Symptoms and Causes – Mayo Clinic, 2022).
Anemia: Anemia is a disorder that occurs when the body lacks sufficient amounts of hemoglobin or healthy red blood cells. Red blood cells consist of a protein called hemoglobin, responsible for transporting oxygen from the lungs to the body’s other organs. The body’s tissues do not receive enough oxygen when there is insufficient hemoglobin or red blood cells, which can cause signs and symptoms such as fatigue and weakness (Lam, 2023). A complete blood count (CBC) test is used to diagnose Anemia. This test counts the red blood cells in your body and the amount of hemoglobin it contains. The findings can reveal if you have Anemia and how serious it is. In order to treat Anemia, the underlying cause is often addressed. You might need to take iron supplements or consume more foods high in iron if, for instance, Anemia is brought on by an iron shortage. Treatment for more severe conditions could require hospitalization or medical treatments (Lam, 2023).
Scleroderma: Scleroderma, commonly known as systemic sclerosis, is a category of rare conditions characterized by skin hardness and tightness. It can also impact blood vessels, internal organs, and the digestive tract. Skin changes might explain dryness and brittleness of the skin and hair. Scleroderma is classified into two types: localized and systemic. Localized scleroderma affects just the skin, generally in a few areas, while systemic scleroderma affects the skin, blood vessels, muscles, and internal organs (Professional, n.d.).

PLAN

Plan: • Assess the diagnosis. Consult a certified medical professional for further treatment if the problem gets worse.
Diagnostics: Perform TSH Test, T4 Thyroxine Test and T3 Triiodothyronine Test.
Labs: In carrying out these tests, TSH Test, T4 Thyroxine Test, and T3 Triiodothyronine Test, it is also essential to carry out a complete blood count (CBC) test to eliminate Anemia.
Pharmacologic intervention: levothyroxine tablet of 12.5 to 25 mcg taken orally once a day and adjusted at 6 to 8-week intervals. CoQ10 (Coenzyme Q-10) tablet of 200 mg daily for the next six weeks.
Non-pharmacologic intervention: Besides other treatment options, a well-balanced diet, regular physical exercises, and stress management may help improve overall well-being.
Referrals: None
Follow-up: Regular follow-up checks with a healthcare provider between 6 and 7 weeks are essential to monitor this condition and adjust treatment as necessary.

References

Eske, J. (2019, January 8). What are the benefits of CoQ10? https://www.medicalnewstoday.com/articles/324113

Hypothyroidism (underactive thyroid) – Symptoms and causes – Mayo Clinic. (2022, December 10). Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284

Lam, P. (2023, January 3). What to know about Anemia. https://www.medicalnewstoday.com/articles/158800

Martin, C. (2022). Hypothyroidism facts and statistics: What you need to know. Verywell Health. https://www.verywellhealth.com/hypothyroidism-facts-6502021

MSN. (n.d.). https://www.msn.com/en-us/health/condition/Hypothyroidism/hp-Hypothyroidism?source=conditioncdx

Professional, C. C. M. (n.d.). Scleroderma. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/8979-scleroderma-an-overview

Shomon, M. (2023). Thyroid medications. Verywell Health. https://www.verywellhealth.com/thyroid-disease-medications-3231845

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NU 650 Week 4 Assignment 1

Please carefully review and follow the SOAP grading rubric and Samples and (1-S, 2-O, 3-A
and 4-P) when completing this assignment. Please write six pages with six or more scholarly
sources which are not more than five years old.
Due:
Value: 100 points
Due: Day 7
Gradebook Category: Assignments: SOAPs
Overview
The goal of this assignment is to practice writing a SOAP note for a sick or episodic visit
related to the focus system(s) reviewed in this week’s learning materials. Review the
SOAP Note Rubric.
Instructions
Choose an abnormal finding related to the content that was covered this week.
Examples from this week would include: hair loss, thickening of the nails, rash, skin
lesion, fatigue, malaise, etc.
Develop a focused SOAP note for the abnormal finding. You do not need to find a patient
to match this finding. The point is for you to think about what the HPI would be, what the
rest of the history may look like, what the objective findings will be, the potential
differential diagnoses, and the plan. In other words, you are creating the patient scenario
and documenting it in SOAP format. Please be sure to include all relevant information
and not just the system the abnormal finding is in.
Refer to the Grading Rubric Refer to the Grading Rubric to see how your work will be
assessed.

Please carefully review and follow the SOAP grading rubric and Samples and (1-S, 2-O, 3-
A and 4-P) when completing this assignment. Please write five pages with five or more
scholarly sources which are not more than five years old.
Due: Before or by Friday, 22 September 2023, 11:55 AM EST.
Value: 100 points
Due: Day 7
Gradebook Category: Assignments: SOAPs

Overview
The goal of this assignment is to practice writing a SOAP note for a sick or episodic visit
related to the focus system(s) reviewed in this week’s learning materials. Review the
SOAP Note Rubric.
Instructions
Choose an abnormal finding related to the content that was covered this week.
Examples from this week would include: hair loss, thickening of the nails, rash, skin
lesion, fatigue, malaise, etc.
Develop a focused SOAP note for the abnormal finding. You do not need to find a patient
to match this finding. The point is for you to think about what the HPI would be, what the
rest of the history may look like, what the objective findings will be, the potential
differential diagnoses, and the plan. In other words, you are creating the patient scenario
and documenting it in SOAP format. Please be sure to include all relevant information
and not just the system the abnormal finding is in.
Refer to the Grading Rubric Refer to the Grading Rubric to see how your work will be
assessed.

Readings
Required
Bickley, L. (2021). Bates' guide to physical examination and history taking (13th ed.).
Lippincott, Williams, & Wilkins.
 Chapter 10: Skin, Hair, and Nails
 Chapter 25: Assessing Children: Infancy Through Adolescence
 Chapter 26: The Pregnant Woman
 Chapter 27: The Older Adult
Dains, J.E., Baumann, L.C., & Scheibel, P. (2020). Advanced health assessment and
clinical diagnosis in primary care (6th ed.). Elsevier.
 Chapter 28: Rashes and Skin Lesions

Bates Videos Lectures
Please view the mini-videos below to learn more about the specific components of the
physical exam. We have listed each mini-video here so that students can better manage
their time as well as have a quick access to revisit a specific component of the exam.
However, when students enter the Bates Physical Exam website, they will be able to

choose a “play all” option that allows all videos to be viewed in succession by each
system.
Skin and Abdomen:
Vol 1: Head-to-Toe Assessment: Adult
 1.4 Skin (1:30 minutes)
o 1.4 Skin Transcript
Vol 2: Head-to-Toe Assessment: Infant
 2.4 Skin (1:42 minutes)
o 2.4 Skin Transcript
Vol 3: Head-to-Toe Assessment: Child
 3.4 Skin (0:42 minutes)
o 3.4 Skin Transcript
Vol 4: Head-to-Toe Assessment: Older Adult
 4.5 Skin (1:09 minutes)
o 4.5 Skin Transcript

Vol 6: Skin
 6.1 Introduction (0:45 minutes)
o 6.1 Introduction Transcript
 6.2 Health History (0:54 minutes)
o 6.2 Health History Transcript
 6.3 Anatomy and Review (4:18 minutes)
o 6.3 Anatomy and Review Transcript
 6.4 Examining the Skin (5:41 minutes)
o 6.4 Examining the Skin Transcript
 6.5 Examining the Hair and Nails (0:26 minutes)
o 6.5 Examining the Hair and Nails Transcript
 6.6 Recording Your Findings (0:55 minutes)
o 6.6 Recording Your Findings Transcript

Instructor Video Mini-Lectures

Subjective Skin (0:51 minutes)

1.
Subjective Skin Video Transcript

Objective Skin (0:59 minutes)

1.
Objective Skin Video Transcript

Skin Lesions (1:20 minutes)

1.
Skin Lesions Video Transcript

Nail and Hair (0:40 minutes)

1.
Nail and Hair Video Transcript

Location Distribution (0:14 minutes)

Location Distribution Video Transcript

Shape and Pattern (0:42 minutes)

1.
Shape and Pattern Video Transcript

Associated Changes (1:00 minutes)

Associated Changes Video Transcript

Pediatric Skin Consideration (2:00 minutes)

Pediatric Skin Consideration Video Transcript

Laboratory Tests (1:15 minutes)

1.
Laboratory Tests Video Transcript

Primary Lesions (2:33 minutes)

1.
Primary Lesions Video Transcript

Secondary Skin Lesions (3:02 minutes)

NU 650 Week 4 Assignment 1