Nursing Homework week 2, Clinical

acabrera25
Patientweek2SOAP.docx

Patient female, 42 years old, Hispanic, nonsmoker

Chief complaint: "I came for my thyroid follow-up."

Returns to the clinic for follow-up of hyperthyroidism. Reports adherence to methimazole. Denies loss of weight, tremors, or palpitations. Complaints of fatigue, but mentions it is an improvement from the last visit. Alert and oriented. Mild tachycardia. Thyroid palpation without enlargement or nodules. No tremor. Warm skin, no diaphoresis. Hyperthyroidism, stable on current treatment (E05.90). Continue methimazole 10 mg daily. Repeat TSH, Free T4 ordered. Monitoring for symptoms. RTC 3 months. Medication compliance counseling provided.