Clinical Case Presentation 4 Jessica Gordon Ron and Kathy Assaf College of Nursing NSG 5590: FNP Capstone Dr. Janice Linton March 21st, 2024 Subjective Chief complaint Lab Review History of present illness The patient is a 21 year old female that presents to the office for a review of bloodwork. Denies any concerns/complaints at this time. Past medical history Vitamin D deficiency Social History Maintains a regular diet with no restrictions Exercises regularly Denies tobacco/alcohol use Allergies None Medications Vitamin D3 1,500 units daily 2 Objective Vitals T 97.9 P 70 R 16 BP 95/71 SpO2 99% Physical Exam General: The patient is pleasant, alert and responsive in NAD. Neck: Supple with no masses or adenopathy. Thyroid normal, without lesions or goiter. Cardiovascular: Regular rate and rhythm. S1, S2 heard, no S3. No rubs, murmurs, or gallops appreciated. Neuro: Alert and oriented X3. Gait is normal. Skin: Normal in color and in texture. No rashes or abnormal lesions noted. Psych: Mood appears normal with no evidence of depression, agitation, or abnormal response. Pertinent Labs TSH: 9mIU/l Free T4: Normal 3 Assessment/Plan Primary Diagnosis Subclinical Hypothyroidism A/P • Explained results of bloodwork to the patient • Discussed regular monitoring of TSH, T3, and T4 levels • Educated the patient about the disease process • Educated the patient about signs and symptoms that could indicate disease progression and when to contact the office Differential Diagnosis Primary hypothyroidism Secondary hypothyroidism 4 (Buttaro et al., 2020) Reflection What did I learn Patients with subclinical hypothyroidism are typically asymptomatic with mildly elevated TSH and normal T3 and T4 levels. It is most often caused by Hashimoto’s thyroiditis. Individuals with subclinical hypothyroidism can be monitored without treatment. What would I do differently Consider ordering antithyroid peroxidase antibodies testing in patients presenting with subclinical hypothyroidism to identify if the cause is autoimmune. (Biondi et al., 2019) 5 References Biondi, B., Cappola, A. R.,