Episodic/Focused SOAP Note
Patient Information:
C.L, 32-years-old, female
Subjective
Chief Complaint: (“feeling tired” and “hair falling out”)
HPI: The client is a 32-year-old female patient who came to the facility complaining of tiredness and hair falling out. The client explained that she has experienced significant weight gain. She noted that in one year, she has gained over 30lbs. However, she pointed out that her appetite has declined sharply.
Location: head and body
Onset: 1 year
Character: significant weight gain,
Associated signs and symptoms: hair falling out, feeling cold, sleeping problems
Timing: N/A
Exacerbating/ relieving factors: N/A
Severity: N/A
Buy this excellently written paper or order a fresh one from ace-myhomework.com
© 2021 Walden University, LLC Page 1 of 8
Current Medications: The client is not on any medications currently
Allergies: The client is allergic to penicillin
PMHx: last tetanus shot May 14, 2019; No surgery, hospitalization, or blood transfusion yet.
Soc Hx: The client is a teacher at a local school. She takes alcohol during social events but does not take substances. She does not exercise regularly. She is married with two children.
Fam Hx:
Her mother suffers from diabetes and hypertension.
Her father has no major health issues.
The client’s siblings are healthy.
Her 47-year-old aunt was diagnosed with hypothyroidism in 2012.
ROS:
GENERAL: The client reported weight gain, decreased appetite, and extreme fatigue. Negative for malaise and fever
HEENT:
Head: No cranial injuries, deformities, and persistent headaches; she, however, reported hair loss
Eyes: No decrease in visual acuity, blurring of vision, and yellow sclera.
Ears, Nose, Throat: No hearing abnormalities, nasal congestion, and sneezing. She denies having a sore throat.
SKIN: No ulcers, rashes, bruises, and inflammation
CARDIOVASCULAR: She denies chest ache, pressure, and discomfort. No chest edema.
RESPIRATORY: she does not experience elevated sputum production, dry cough, and shortness of breath.
GASTROINTESTINAL: No abdominal pain, vomiting, and other symptoms, including constipation, diarrhea, and constipation
GENITOURINARY: No stinging or burning while urinating.
NEUROLOGICAL: Denies lightheadedness, syncope, and paralysis. No ataxia and numbness in the feet and hands. No incontinence.
MUSCULOSKELETAL: Denies muscular ache and joint rigidity
HEMATOLOGIC: No bruising, anemia, and nose bleeding
LYMPHATICS: negative for inflamed nodes and splenectomy.
PSYCHIATRIC: Negative for depressive feelings and anxiety. Positive for insomnia
ENDOCRINOLOGIC: she reported cold intolerance.
Objective © 2021 Walden University, LLC Page 3 of 8
Vital signs: T- 97.4, P 79, R-19/min, BP- 136/76, Weight 164 lbs
General— The client has a good physical stature, and is well-groomed with no distressful signs.
HEENT
Head: The client has identifiable signs of baldness but no head injuries
Eyes: The conjunctiva is pink, No signs of reddened eyes, inflammation, and excessive tearing, the sclera is white.
Ears: No abnormal ear discharge, and the ear canals are open. The tympanic membrane is not inflamed.
Nose: No nasal inflammation, congestion, and excess mucus secretion
Neck: the client’s neck is lithe with no identifiable signs of lymphadenopathy
Mouth/Throat: The mouth and throat are not erythematous, and the tonsils are not inflamed
Skin: The skin texture is appropriate for the client’s age. No signs of scaling, lesions, or injuries noted
Cardiovascular- Normal S1/S2, No gallops, and clicks
Gastrointestinal — No abdominal obesity, scars, and distension; Bowel sounds detected in the four quadrants
Pulmonary— Lung auscultation detects soft, breezy sounds with no labored breathing
Musculoskeletal: Joint edema not detected. The range of motion is not decreased in the extremities
Neurological: The cranial nerves are not injured, no face drooping.
Diagnostic results:
TSH test – 0.120
© 2021 Walden University, LLC Page 4 of 8
Thyroglobulin test- 0.5
Free T4 test – 1.34
Complete blood count -
Physical examination- signs of baldness due to falling out hair
Assessment
Primary Diagnosis
Hypothyroidism (E03.9): The symptoms of this condition, as clarified by Wangnoo, Ahmad, and Siddiqui (2017), include intense fatigue, weight gain, muscular weakness, and cold intolerance. The client reported remarkable weight gain over a year, sensitivity to cold, and fatigue. Hair loss is also a noticeable symptom of hypothyroidism.
Differential Diagnoses
Depression (F32.9): Depression is a possible diagnosis for the patient since she presented with extreme fatigue, sleep problems, loss of appetite, and weight gain (Wangnoo, Ahmad & Siddiqui, 2017)
Anemia (D64.9): Anemia is associated with a decreased level of red blood cells in the body. The symptoms of this disorder include intense fatigue and increased sensitivity to cold (Willis, 2016)
Chronic fatigue syndrome (R53.82): This disorder is typified by intense fatigue, muscular pain, headaches, and sleep problems. Heart palpitations and flu-like symptoms are also present in chronic fatigue syndrome (Myhill, 2018).
Plan
Additional assessments
TSH test
Thyroglobulin test
Pharmacological intervention
One tablet levothyroxine 25mcg daily (NHS, 2021)
Non-pharmacological interventions
The client to include healthy food products, including fruits and vegetables, in her diet
Client Education
The clinician advised the client to stop consuming alcohol, eat healthy foods, exercise frequently, and drink adequate fluids (NHS, 2021).
Return to office
The follow-up plan states that the client should return to the office after four weeks for further assessment
© 2021 Walden University, LLC Page 6 of 8
Self-Assessment
The interaction with the client was satisfying and the necessary tests for suspected cases of hypothyroidism were performed. In the future, an x-ray test could be performed on patients with similar symptoms. This test is relevant for generating clear images to identify thyroid deformities. The treatment plan involved administering levothyroxine, a synthetic hormone that restores thyroid hormones balance (NHS, 2021).
References
Myhill, S. (2018). Diagnosis and treatment of chronic fatigue syndrome and myalgic encephalitis. Chelsea Green Publishing.
NHS (2021). Treatment - Underactive thyroid (hypothyroidism).
https://www.nhs.uk/conditions/underactive-thyroid-hypothyroidism/treatment/
Wangnoo, S., Ahmad, J., & Siddiqui, M. (2017). Principles and practices of thyroid gland disorders. Jaypee.
Willis, R., (2016). Anemia: Diagnosis and treatment. Hayle Medical.
