Endocrine SOAP note

HPI: Ms. Donetz is a 73-year old Female who comes into your office with concerns of fatigue and dry skin. She is a retired Banker. She is AAOx4, ambulatory, and lives by herself. She does report increased fatigue no matter how much sleep she gets.  She is also concerned that she may need to come off of one of her meds because her hair is thinning.  She had labs done and also was informed they would review results at this visit. Other pertinent diagnoses include Hypertension, Hyperlipidemia, and Vitamin D deficiency. She admits to not taking her vitamin D daily as prescribed.

She makes no unusual motor movements and demonstrates no tics. She denies any visual or auditory hallucinations. She denies any suicidal thoughts or ideations. She denies any falls or pain.

(All other Review of System and Physical Exam findings are negative other than stated.)

Vital Signs: BP 137/82, HR 89, RR 20, Temp 98.1

PMH: Hypertension, Hyperlipidemia, Vitamin D deficiency

Allergies: I.V. Contrast - rash, ACE Inhibitors - cough

Medications:

· Women’s One A Day-Multivitamin daily

· Chlorthalidone 25mg daily

· Fish Oil 1 tablet daily

· Amlodipine 5mg p.o. daily

· Losartan 100mg p.o. daily

· Atorvastatin 40mg p.o. at bedtime daily

· Ergocalciferol 50,000 units PO once a month

Social History: as stated in Case Study

ROS: as stated in Case study

Diagnostics/Assessments done:

1. CXR- Last CXR showed no cardiopulmonary findings. WNL

2. TSH/Free T4, T3- as noted below in lab results

3. Basic Metabolic Panel and CBC as shown below

4. Vitamin D Level- as noted below in lab results

TEST	RESULT	REFERENCE RANGE
GLUCOSE	85	65-99
SODIUM	134 L	135-146
POTASSIUM	4.2	3.5-5.3
CHLORIDE	104	98-110
CARBON DIOXIDE	29	19-30
CALCIUM	9.0	8.6- 10.3
BUN	20	7-25
CREATININE	1.01	0.70-1.25
GLOMERULAR FILTRATION RATE (eGFR)	76	>or=60 mL/min/1.73m2

 

TEST	RESULT	REFERENCE RANGE
TSH	23	0.4-4.0
FREE T4	0.05	0.9-2.4 mcg/dl
T3	3.0	2.0-4.4 ng/dl
Vitamin D 1,25 OH	14	36-144

 

TEST	RESULT	REFERENCE RANGE
WBC	7.3	3.4- 10.8
RBC	4.31	4.5 – 6.1
HEMOGLOBIN	14	13-17.2
HEMATOCRIT	42%	36-50
MCV	90	80-100
MCHC	34	32-36
PLATELET	272	150-400