The Traditional Narrative
CASE STUDY 4: Focused Thyroid ExamChantal, 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 depressedCase Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format .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.Episodic/Focused SOAP Note TemplatePatient Information:Initials, Age, Sex, RaceS.CC (chief complaint) a BRIEF statement identifying why the patient is here – in the patients own words – for instance “headache”, NOT “bad headache for 3 days.HPI: This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. Use LOCATES Mnemonic to complete your HPI. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes of each principal symptom in paragraph form not a list. If the CC was headache, the LOCATES for the HPI might look like the following example:Location: headOnset: 3 days agoCharacter: pounding, pressure around the eyes and templesAssociated signs and symptoms: nausea, vomiting, photophobia, phonophobiaTiming: after being on the computer all day at workExacerbating/ relieving factors: light bothers eyes, Aleve makes it tolerable but not completely betterSeverity: 7/10 pain scaleCurrent Medications: include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Allergies: include medication, food, and environmental allergies separately (a description of what the allergy is ie angioedema, anaphylaxis, etc. This will help determine a true reaction vs intolerance).PMHx: include immunization status (note date of last tetanus for all adults), past major illnesses and surgeries. Depending on the CC, more info is sometimes needed
