NR 511 WEEK 6 SOAP NOTE Michael 10 YO Subjective Chief Complaint Fatigue (NR511)

Exam (elaborations) NR 511 WEEK 6 SOAP NOTE Michael 10 YO Subjective Chief Complaint Fatigue (NR511) Michael 10 years Subjective Chief complaint: fatigue; “We have both been usually tired. I have noticed Michael has not been himself for a few weeks, maybe more.” History of present illness (HPI): O: Onset- Approximately a few weeks possibly more L: Location—Not reviewed D: Duration-current disposition C: Characteristics/Associated symptoms- polydipsia, weight loss, bed wetting, sleeping more, does not want to play out doors, can’t keep up with the other kids in gym class, gets dizzy, never hungry A: Aggravating factors- Not reviewed R: relieving factors- Not reviewed T: Treatments- Not reviewed S: Severity-inability to play outdoors and keep up with kids in class Past Medical History: Mother reports general health as good: no childhood or chronic illnesses. Surgeries: none. Hospitalizations: none. Immunizations: UTD: allergies: Penicillin, gets a rash no ETOH, tobacco, illicit drugs. Sleeping 8-10 hours a night. Medications: daily multivitamin Family History: Parents and siblings are in good health, MGM: HTN and hyperlipidemia. MGF: HTN and hyperlipidemia. Paternal grandparents deceased: PGM: brain Ca, PGF: leukemia Social History: Good student, oldest of four children. Lives with parents, grandparents and siblings. Have 2 dogs and a cat. Review of Systems: Neurologic: dizziness, fatigue Head/Eyes/Ears/Nose/Mouth/Throat: Integumentary: rash on elbows Cardiovascular: not reviewed Respiratory: not reviewed Genitourinary: bed wetting Gastrointestinal: not reviewed Musculoskeletal: not reviewed Hematologic: not reviewed Endocrine: polydipsia, weight loss, bed wetting, sleeping more Objective VS Height: 48 inches weight 78 pounds BP 110/70 BMI 23.8 T 98.2 P 65 R 16. CBC: WBC 7, Hgb 14 Hct 40 RBC 4.3 MCV 78 MCHC 34 RDW 11.5 Fasting glucose 136 mg/dL TSH: 2.6 mIU/L free T4 15 pmol/L General: Caucasian male child, appears stated age, Alert and cooperative, appears tired and distracted. Skin: color is pale pink, no cyanosis or pallor. Skin cool, dry and intact. Poor turgor. No moles or skin changes. HEENT: head normocephalic. Hair thick and distribution even throughout scalp. Eyes: Sclera clear. Conjunctiva: white, PERRLA, EOMs intact. Ears: Tympanic membranes gray and intact with light reflex noted. Pinna and tragus nontender Nose: Nares patent without exudate. Sinuses nontender to palpation. Throat: Oropharnx dry, no lesions or exudate. Tonsils ¼ bilaterally. Teeth in good repair, no cavities noted. Neck supple. No cervical lymphadenopathy or tenderness noted. Thyroid midline, small and firm without palpable masses. Lungs: Lungs clear to auscultation bilaterally. Respirations unlabored.CV: Heart S1 and S2 noted, RRR, no murmurs, noted. PMI at 5th ICS. Peripheral pulses equally bilaterally. Abdomen: Abdomen round, soft, with hypoactive bowel sounds noted. No organomegaly noted. MS: reflexes WNL. Gait steady. Assessment 1. Juvenile Diabetes (ICD 10: E10.9)- According to Choudhary et al. (2015) the pathophysiology of type 1 diabetes develops as a result of autoimmune pancreatic beta-cell destruction in genetically susceptible individuals. Up to 90% of patients will have autoantibodies to at least one of 3 antigens: glutamic acid decarboxylase (GAD); insulin; and a tyrosine-phosphatase-like molecule, islet autoantigen-2 (Choudhary et al., 2015). The clinic presentation of type 1 diabetes mellitus include the symptoms of polydipsia, polyuria, and weight loss with hyperglycemia and ketonemia. According to Choudhary et al. (2015) patients with these symptoms usually present in the ambulatory setting appearing slightly ill, with vague complaints, such as weight loss and lethargy. a. In particular, to this patient, based upon the fasting plasma glucose level of 136 the patient is considered a diabetic. Normal levels in respect to a fasting plasma glucose are less than 100, and the prediabetic range is 100-125 (Choudhary et al., 2015). Secondly the additional symptoms of polydipsia, polyuria, and lethargy contribute to the diagnosis. This study source was downloaded by from CourseH on 0 2. Hyperthyroidism (E07.9). Hyperthyroidism is any condition of the thyroid gland that causes overproduction of the thyroid hormone. The pathophysiology of this disease according to Bahn et al. (2011) is related to the binding of TSH to receptors on the thyroid gland which leads to the release of thyroid hormones. In turn, elevated levels of these hormones act on the hypothalamus to decrease TRH secretion and thus the synthesis of TSH. This condition can be related to autoimmune conditions, thyroiditis, genetic conditions, toxic nodules, and pituitary adenomas, but the most common cause of pediatric hyperthyroidism is Grave’s disease. a. In particular, to this patient diagnostic results reveal an elevated free T4 level suggestive of hyperthyroidism. Secondly, per the mother of the patient he hasn’t eaten much with the potential for recent weight loss, as well as increased thirst as evidence by the mother stating his abnormal over consumption of water is suggestive of diagnosis. 3. Thyroid hormone resistance syndrome (ICD 10: E07.89)- The diagnosis is based on the clinical findings and standard laboratory tests and confirmed by genetic studies. TH deficiency and excess are associated with typical symptoms and signs reflecting the global effects of lack and excess of the hormone, respectively, on all body tissues (Weiss, Dumitrescu, & Refetoff, 2010). Diagnosis is based on persistent elevations of serum free T4 and often T3 levels in the absence of TSH suppression, and confirmation in most cases is by way of genetic testing (Weiss et al., 2010). The mainstay in the management of RTH patients who are asymptomatic is to recognize the correct diagnosis and avoid antithyroid treatment. a. Lastly, looking at the patients TSH level 2.6 (normal level 1.80-300) and T4 level 15 (normal level 6.00-12.00). The patient is noted to have thyroid hormone resistance syndrome which is a mutation in the thyroid hormone receptor decreases thyroid hormone function. Plan 1. Medications a. This patient is in need of immediate evaluation by an endocrinologist, prior to medication management. b. The honeymoon period according to Choudhary et al. (2015), can last up to 2 years after diagnosis, is characterized by good glycemic control and low insulin requirements (0.5 units/kg/day) (Choudhary et al., 2015). Secondly, a log comprised of meals and activity are needed to customize this patient’s plan of care. Lastly, due to the age of this patient I believe there is opportunity to educate and change eating habits. 2. Additional diagnostic tests a. Urinalysis for glucose, ketones, and microalbuminuria b. C-peptide insulin level to differentiate from type two diabetes c. Hemoglobin A1C 3. Patient education