NU636 SOAP note for a 53-year-old woman with TSH of 93

The case is written so the diagnosis is not the exercise. A TSH of 93 with fatigue, weight gain despite regular exercise, a goitre, dry skin, bradycardia at 60 with a raised diastolic pressure, and a delayed relaxation phase of the Achilles reflex is overt primary hypothyroidism, and the delayed reflex in particular is a classic finding that exists in the vignette precisely because it points one way. What is being assessed is whether you can lay that out as an abbreviated SOAP note: sorting the given information into subjective and objective correctly, writing an assessment that reasons rather than asserts, and building a plan specific enough to be followed. Resist the pull to write an essay about thyroid physiology. The format is the assignment, and information placed in the wrong section is the most common and most avoidable loss of marks. Write the headings before you write anything under them.

Sorting subjective from objective is not automatic here because of where the labs came from. Subjective is what she reports: fatigue, low motivation, the fifteen pound gain despite teaching yoga two to three times weekly, the menopausal history with symptoms that resolved, denial of dysphagia and neck pain, and the reason she sought the outside testing. Objective is what you measured or observed: the vital signs, the height and weight, the neck findings, the cardiac and respiratory examination, the skin, and the reflex. The TSH result is the interesting case, because she brought it rather than you ordering it. The defensible treatment is to record it as objective data with its source noted, since it is a laboratory value rather than a report of symptoms, while flagging that testing done outside your system may need repeating for confirmation. Saying that in a single line shows judgement about provenance, which is a real issue when patients arrive with results from a retail laboratory.

The assessment section should show reasoning rather than announce a diagnosis. State the working diagnosis, then say what in the data supports it and what you would want to distinguish. The most useful distinctions are between primary hypothyroidism and central hypothyroidism, which a very high TSH effectively excludes, and between autoimmune thyroiditis and other causes of primary failure, which is where thyroid peroxidase antibodies come in. The asymmetric goitre deserves a sentence of its own rather than being folded into the thyroid diagnosis, because asymmetry and nodularity raise a separate question that antibodies will not answer. Note also what her symptoms could plausibly have been attributed to if the TSH had not been available: perimenopause, depression, anaemia, sleep disorder. Naming those shows differential reasoning rather than post hoc confirmation. It also gives your assessment somewhere to go beyond restating the number, which is what a marker is looking for in a section that could otherwise be one sentence long.

The plan is where the prompt is most specific, so follow its structure literally. Diagnostics first: free T4 to confirm and quantify, thyroid peroxidase antibodies for aetiology, and consideration of imaging for the asymmetric gland. Then treatment, and here precision matters. Levothyroxine is the treatment; the discussion points are whether to start at a full weight-based replacement dose or to titrate up, and the case for caution in a woman of this age turns on cardiac risk rather than on age alone. Give a starting dose with your reasoning, and say the administration instructions explicitly, since fasting, separation from calcium, iron and coffee, and consistency of timing are the things that actually determine whether treatment works. Weight-based calculations are easy to state and easy to check, so show the arithmetic rather than naming a dose that appears from nowhere. Say what you would do differently if she had known cardiac disease.

Education, follow-up and referral complete the plan and each has a specific answer in this case. Education covers what the medication does, that it is lifelong, that symptom improvement lags biochemical improvement by weeks, and which symptoms warrant contact sooner. Follow-up is a repeat TSH at six to eight weeks, because that is the interval at which the axis has re-equilibrated, and a plan for titration from that result. Referral or consultation should address the asymmetric goitre rather than the hypothyroidism, which is manageable in primary care. The prompt also asks about consultation while the patient is still in the office, which invites a judgement: this case does not require it, and saying so with a reason is a better answer than manufacturing an urgency the vignette does not support. Consultation and referral are different decisions with different timescales, and the prompt asks about both.

On execution, keep the note abbreviated as instructed, use the four headings, and write in note register rather than in essay prose. Every element of the plan should be supported by scholarly resources, which the prompt states explicitly, so cite for the dosing approach, the follow-up interval and the antibody testing rather than for the diagnosis itself. In-text citations and full references in APA are required, and the post and responses carry forty points against a rubric. Finally, do not add findings the vignette does not contain. Inventing a family history or a symptom to strengthen your reasoning is the one error that undermines the whole exercise, since working within incomplete information is the clinical skill being taught. Work with what the vignette gives you and note the gaps as gaps, which is what the plan's diagnostic section exists to close. Every added finding is one a marker can check against the scenario.