NUR 616 Module 4 SOAP Note Example

SOAP Note: Subclinical Hypothyroidism and Fatigue in a 72-Year-Old Woman, a Decision Not to Treat

[Student Name]

Southern New Hampshire University

NUR 616: Primary Care of Adults and Gerontological Patients

Module Four SOAP Note

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

SOAP Note: Subclinical Hypothyroidism and Fatigue in a 72-Year-Old Woman, a Decision Not to Treat

Subclinical hypothyroidism, a raised TSH with a normal free thyroxine, is one of the most common abnormal results in older adults, and levothyroxine is one of the most prescribed drugs in the United States. The two meet often, sometimes without evidence that the patient benefits. This SOAP note documents an older woman with fatigue and a mildly raised TSH. It argues that her TSH should be interpreted against the higher values normal for her age, that a randomized trial in older adults shows treatment would not relieve her tiredness and that the right plan is to look for other causes and monitor.

Subjective

Chief concern: "I've been tired for months, and I wondered about my thyroid."

History of present illness: Mrs. A. is a retired librarian, 72, who has felt tired most afternoons for about six months, needing to sit down after an hour of gardening that she used to do all morning. She falls asleep easily at 10 p.m. but wakes several times a night and is up by 5 a.m. She denies weight gain, hair loss, hoarseness and swelling of the face or legs. She has mild constipation, which she has had for years, and feels cold more than her husband does. Her mood is "a little flat" since her closest friend moved away in the spring. According to her husband, the snoring is loud enough to hear from the hallway, and some nights it goes quiet for several seconds before a gasp.

Past history: hypertension; osteopenia. Medications: losartan 50 mg daily, calcium with vitamin D. No amiodarone, lithium or biotin supplements. Allergies: none. Family history: sister with Hashimoto thyroiditis. Social: never smoked, one glass of wine weekly, walks her dog daily.

Review of systems: General: fatigue; weight stable. Cardiovascular and respiratory: she denies chest discomfort, a racing heart, cough and breathlessness. Gastrointestinal: chronic mild constipation; no blood in stool. Psychiatric: low mood as above; enjoys her grandchildren; no thoughts of self-harm. Hematologic: no bleeding.

Objective

Vital signs: blood pressure 128/76 mm Hg, pulse 64 and regular, weight 63 kg, unchanged from a year ago, BMI 25.

Examination: alert, conversant, not slowed in speech or movement. Skin: normal texture; no coarse or dry patches. Neck: thyroid palpable, smooth, slightly enlarged, without nodules or tenderness; circumference 37 cm. Mouth: crowded oropharynx, Mallampati class 3. Heart: regular, no murmur. Extremities: no edema. Neurologic: ankle reflexes 2+ with normal relaxation phase.

Laboratory results: TSH 7.2 mIU/L with a free T4 of 1.1 ng/dL, inside the laboratory's normal range, on the first test; repeat TSH after eight weeks 6.9 mIU/L with free T4 1.0 ng/dL. Thyroid peroxidase antibodies positive at 210 IU/mL. Complete blood count and metabolic panel normal. Lipids: LDL 118 mg/dL.

Assessment

1. Subclinical hypothyroidism, persistent on two tests eight weeks apart, with positive thyroid peroxidase antibodies suggesting autoimmune thyroiditis. Her TSH is only modestly raised. In a large US population sample, the TSH distribution shifted upward with age, and in people aged 80 and older the 97.5th percentile approached 7.5 mIU/L, so many older adults labeled as having subclinical hypothyroidism have values within the range for their age (Surks & Hollowell, 2007). Positive antibodies do increase her chance of progressing to overt hypothyroidism over time, which justifies monitoring.

2. Fatigue, most likely multifactorial. Loud snoring with witnessed pauses, fragmented sleep and a crowded airway make obstructive sleep apnea likely; low mood after a social loss is a second contributor. Her thyroid result is unlikely to be the main cause.

Treatment decision: in the TRUST trial, 737 adults aged 65 and older with persistent subclinical hypothyroidism were randomized to levothyroxine or placebo. After one year, TSH fell in the treated group, but there was no difference in hypothyroid symptoms or tiredness scores between groups (Stott et al., 2017). A guideline panel reviewing trials in adults with TSH below 20 mIU/L made a strong recommendation against thyroid hormone for most people, excepting women trying to become pregnant (Bekkering et al., 2019). For Mrs. A., treatment would add a daily drug and the risk of overtreatment, which in older adults includes atrial fibrillation and bone loss, without evidence that she would feel better.

The thyroid is not the whole story in the note, however, and the pertinent negatives are recorded for a reason. A stable weight, normal reflex relaxation, normal skin and speech and a normal blood count make overt hypothyroidism and anemia unlikely explanations for her fatigue. A normal metabolic panel excludes kidney disease, high calcium and diabetes as hidden causes. These findings narrow the search to her sleep and her mood, which the plan addresses first.

Plan

Thyroid: no levothyroxine. Repeat TSH and free T4 in 12 months, or sooner if new symptoms such as weight gain, swelling or slowed thinking appear; treatment would be reconsidered if TSH rises above 10 mIU/L or free T4 falls. Sleep: STOP-BANG questionnaire today, score 5; referral for a home sleep study. Mood: PHQ-9 today, score 7, mild symptoms; she agreed to join a library volunteer group her friend had belonged to and will return in six weeks to recheck mood. Lipids: 10-year cardiovascular risk to be calculated at the next visit. Follow-up in six weeks to review the sleep study and mood.

Education

Mrs. A. was told that her thyroid is slightly underactive on blood tests, probably from a common autoimmune condition her sister also has, but not enough to cause her tiredness, and that a large study in people her age found thyroid pills did not improve energy. She was told what symptoms would prompt earlier testing and why sleep apnea is worth checking. She said she was relieved not to add another pill.

Conclusion

Mrs. A.'s mildly raised TSH is real but, at her age, modest, and the best evidence shows that treating it would not relieve her fatigue. Recording the age context, the trial evidence and the more likely causes of her tiredness justifies a plan that treats her symptoms rather than her laboratory value.

References

Bekkering, G. E., Agoritsas, T., Lytvyn, L., Heen, A. F., Feller, M., Moutzouri, E., Abdulazeem, H., Aertgeerts, B., Beecher, D., Brito, J. P., Farhoumand, P. D., Singh Ospina, N., Rodondi, N., van Driel, M., Wallace, E., Snel, M., Okwen, P. M., Siemieniuk, R., Vandvik, P. O., . . . Vermandere, M. (2019). Thyroid hormones treatment for subclinical hypothyroidism: A clinical practice guideline. BMJ, 365, Article l2006. https://doi.org/10.1136/bmj.l2006

Stott, D. J., Rodondi, N., Kearney, P. M., Ford, I., Westendorp, R. G. J., Mooijaart, S. P., Sattar, N., Aubert, C. E., Aujesky, D., Bauer, D. C., Baumgartner, C., Blum, M. R., Browne, J. P., Byrne, S., Collet, T.-H., Dekkers, O. M., den Elzen, W. P. J., Du Puy, R. S., Ellis, G., . . . Gussekloo, J. (2017). Thyroid hormone therapy for older adults with subclinical hypothyroidism. New England Journal of Medicine, 376(26), 2534-2544. https://doi.org/10.1056/NEJMoa1603825

Surks, M. I., & Hollowell, J. G. (2007). Age-specific distribution of serum thyrotropin and antithyroid antibodies in the US population: Implications for the prevalence of subclinical hypothyroidism. Journal of Clinical Endocrinology & Metabolism, 92(12), 4575-4582. https://doi.org/10.1210/jc.2007-1499