SOAP note

Name:  Y. U

Date: 09/20/2018

Time: 11:30 AM

Age: 45 y/o

Sex: F

SUBJECTIVE

CC:  Follow up Lab result and fatigue

HPI: 

Y.U is a 45-year-old female, who comes to the office today for lab review. She stated that she has gained 10 pound in the last three months and she feels fatigued.

Medications:

· Synthroid tab 100mcg tab 1 tab q/am PO whit empty stomach

PMH

Allergies:  Denies any allergies to food or medication and environmental allergies.

Medication Intolerances: NKDA 

Chronic Illnesses/Major traumas: Depression and hypothyroidism

Hospitalizations/Surgeries: Denies 

Family History

Mother: Alive, HTN

Father: Alive, CAD

Brothers: 1, alive and healthy

Social History

Patient is married and lives with her husband and two children. She works as a manicure. She does not smoke cigarettes. She drinks alcohol socially, denies use of illicit drugs. She normally makes a regular checkup for her health chronic conditions. Family attends church on a regularly and has a good support system. Pets: No. Travel: No. 

ROS

General

Patient is a 45 y/o Hispanic female. Patient complains of fatigue and weight gain. No distress noted at this moment. Appetite decreased

Cardiovascular

Denies chest pain, palpitations, PND, orthopnea, edema, denies palpitations 

Skin

Warm and dry. No rashes bruising or bleeding noticed, skin is appropriated color for ethnicity.

Respiratory

Denies cough, wheezing, hemoptysis, dyspnea

Eyes

 Denies changes in vision, denies blurred vision

Gastrointestinal

Denies vomit or diarrhea. 

Ears

Denies ear pain, hearing loss, ringing in ears, discharge

Genitourinary/Gynecological

Patient denies urinary symptoms (urgency, frequency burning, change in color of urine). No hematuria

Nose/Mouth/Throat

Denies difficulty in smelling, sinus problems, nose bleeds or discharge. Denies dysphagia, hoarseness, throat pain

Musculoskeletal

No limitation of range of motion. Denies any joint pain or any muscle pain

Breast

No changes

Neurological

Denies syncope, seizures, transient paralysis, paresthesia, black out spells

Heme/Lymph/Endo

No bruises, no hematomas, ecchymosis, lymph nodes or mass. Cold intolerance.

Psychiatric

Decrease level of energy.

OBJECTIVE

Weight 140   BMI 25.6 Overweigh

Temp 98.8 F

Pain: 0/10

BP 121/74 mmHg

Height 5’.2” in

Pulse 84 bpm

Resp 18 bpm

General Appearance

Head is normocephalic, atraumatic and without lesions; hair evenly distributed.

Skin

Good turgor, no rashes, well perfused.

HEENT

Head is normocephalic, atraumatic and without lesions; hair evenly distributed. Eyes:  PERRLA. EOMs intact. No conjunctival or scleral injection. Ears: Canals patent. Nose: Nasal mucosa pink; normal turbinates. No septal deviation. Throat: Oral mucosa pink and moist. Pharynx is no erythematous and without exudate. Neck: Supple. Full ROM; no cervical lymphadenopathy.

Cardiovascular

Regular rhythm and rate, normal S1S2, no murmurs.

Respiratory

Symmetric chest wall. Respirations regular and easy; lungs clear to auscultation bilaterally.

Gastrointestinal

Abdomen soft, non-tender, no distended, bowel sound present.

No organomegaly, mass, or herniation

Breast

No mass.

Genitourinary

Bladder is non-distended. External genitalia deferred.

Musculoskeletal

Full ROM seen in all 4 extremities as patient moved about the exam room. Steady gate, no limping or musculoskeletal deformities.

Neurological

Speech clear. Good tone. Posture erect. Balance stable; gait normal.

Psychiatric

Alert, awake.

Lab Tests

CBC, CMP, Lipid profile, TSH, US of the neck and thyroid, screen mammogram

Special Tests

 None.

 Diagnosis

Diagnosis

· Uncontrolled Hypothyroidism

· Depression

· Overweight

Differential diagnosis

1. Ischemic heart disease

2. Hypothyroidism secondary to treatment

3. Nephrotic syndrome

4. Cirrhosis

5. Depression

Plan/Therapeutics

· Plan: 

Illness counseling

Discussed compliance with medication

TSH prior appointment next month, Lab result follow up

RTC or call if no improvement

Patient instructed about the nature and course of hypothyroidism, s/s of disease and medication management. Review the labs: TSH 13 Uu/ml. Rest of the lab normal.

New medication: Increase Synthroid 100mcg to 120 mcg daily q/AM. PO whit empty stomach. Patient continue with the same medication for depression.

References:

McCance, Kathryn, Sue Huether. Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7th Edition. Mosby, 2014. Vital Book file.