history

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study using the episodic/focused note template. (1) Provide evidence from the literature to support diagnostic tests that would be appropriate for each case. (2) List five different possible conditions for the patient's differential diagnosis and (3) justify why you selected each.

Case study: Focused Thyroid Exam Anabel, a 34-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 depressed.

References

Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel's guide to physical examination: An interprofessional approach (9th ed.). St. Louis, MO: Elsevier Mosby.

Sullivan, D. D. (2019). Guide to clinical documentation (3rd ed.). Philadelphia, PA: F. A. Davis.