Episodic/Focused SOAP Note Template

Episodic/Focused SOAP Note Template

Patient Information:

Chantal, 32, Female

CC: Fatigue and hair loss.

HPI: The patient is a 32-year-old female and complains of “feeling tired” and “hair falling out”. She reports that she has gained 30 pounds in the last year despite a marked decrease in appetite. On ROS, she reports not sleeping well and feels cold all the time. She is still able to enjoy her hobbies and does not believe that she is depressed.

Differential Diagnoses

Hypothyroidism

Hypothyroidism refers to a condition that results from an underperforming thyroid gland. That is, the thyroid gland does not produce enough hormones as required for normal body functioning. The result is a slowed-down metabolism, which consequently triggers a myriad of symptoms. The main symptoms that characterize hypothyroidism are fatigue, weight gain, insomnia, depressed mood, reduced appetite, poor concentration, muscle aches, cold intolerance, and hair loss (American Thyroid Association, 2019).

The patient in question presents fatigue, weight gain, insomnia, reduced appetite, hair loss, and cold intolerance. Markedly, these are among the commonest indicators of hypothyroidism. Additionally, the condition is more prevalent in females than males and therefore, the patient, being female, is highly predisposed to the condition.  Blood work is recommended to test the level of hormones secreted by the thyroid gland to establish this gland’s working condition.

Fibromyalgia

Fibromyalgia syndrome is a condition whose main symptoms include: sleep disruption, fatigue and tiredness, and generalized pain. Cold or heat intolerance is sometimes present in fibromyalgia (CDC, 2020). The condition has no definitive diagnostic testing procedures and is mainly diagnosed through differential diagnoses with the patient’s medical history in mind. X-rays and blood work are used mostly for the elimination of similarly presenting conditions.

Diabetes

A patient whose blood sugar level has deviated from the normal is likely to present with such symptoms amidst other more conventional signs of diabetes. Feelings of tiredness, weight gain, insomnia, and hair loss are highly significant in a diabetic patient. Undiagnosed diabetes may have irreversible effects on the patient, some of which may be life-threatening. It is therefore important to consider diabetes in the case at hand. Blood tests can be used to confirm the levels of blood glucose for the patient.

Anemia

Anemia is basically the lowered capacity of the red blood cells to transport oxygen throughout the body optimally. There are different causes of this reduced performance and consequently different types of anemia. However, general symptoms common in all types of anemia include fatigue, insomnia, coldness, and hair loss (Soundarya & Suganthi, 2016). Anemia is one of the major causes of hair loss, and the low blood oxygen causes a reduction in physical energy, and consequently, patients tire easily. Blood work can be used to confirm or eliminate anemia as a possible cause of the above-stated symptoms.

Depression

Depression is a common psychological health condition that interferes with a person’s daily life. Some of the symptoms associated with depression include a constantly depressed mood, anxiety, insomnia, lack of motivation, feelings of tiredness or fatigue, changes in appetite, and irregular sleep patterns. Additionally, most patients lose interest in previously enjoyed activities, and prolonged depression may lead to thinning or loss of hair (Fried & Nesse, 2015). A patient does not have to present all the named symptoms, but a combination of some or all of these symptoms should not be ignored. The patient in the case study may have ruled out depression because she still enjoys all the activities she used to enjoy. However, it is still important to subject her to a psychological test to establish her mental health.

References

American Thyroid Association (2019). Hypothyroidism: A booklet for patients and their families. https://www.thyroid.org/wp-content/uploads/patients/brochures/Hypothyroidism_web_booklet.pdf

CDC. (2020). Fibromyalgia.  https://www.cdc.gov/arthritis/basics/fibromyalgia.htm

Fried, E. & Nesse, R. (2015). Depression sum-scores don’t add up: why analyzing specific depression symptoms is essential. BMC Medicine 13(72), 1-11.

Soundarya, N. & Suganthi, P. (2016). A review on anemia – types, causes, symptoms, and their treatments. Journal of Science and Technology, 1(1), 10- 17.


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