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Case 1: A 40-year-old housewife complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular in the last year. She has an 18-year-old daughter and has been trying to have another child with her new partner but has been unsuccessful.
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive findings that validate your main diagnosis
Pertinent negative findings that make you think of other differential diagnoses
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.