SOAP NOTE

Name:  Y. UDate: 09/20/2018Time: 11:30 AM
 Age: 45 y/oSex: 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   Citalopram tab10 mg tab 1 tab PO OD
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 visionGastrointestinal Denies vomit or diarrhea. 
Ears Denies ear pain, hearing loss, ringing in ears, dischargeGenitourinary/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 painMusculoskeletal No limitation of range of motion. Denies any joint pain or any muscle pain
Breast No changesNeurological 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 ORDER NURSING COURSE WORKS HERE
Weight 140   BMI 25.6 OverweighTemp 98.8 F Pain: 0/10BP 121/74 mmHg
Height 5’.2” inPulse 84 bpmResp 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 Ischemic heart disease Hypothyroidism secondary to treatment Nephrotic syndrome Cirrhosis 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.  
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