Posted: May 1st, 2022

I have been feeling exhausted and my hair is falling out

Episodic/Focused SOAP Note

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Episodic/Focused SOAP Note
Patient Information:
Initials: C, Age: 32, Sex: Female, Race: White
S.
CC: I have been feeling exhausted and my hair is falling out.
HPI: Chantal, a 32-year-old female patient presents to the health facility complaining of exhaustion and hair falling out. She has experienced an unintentional weight gain of 30 pounds for the last one year and low appetite. The patient has been experiencing cold intolerance and sleeplessness. She denied being depressed and enjoys various hobbies.
Current Medications: Vitamins (Ls)Meloxicam Oral 15 Mg 1 Tab(S) Daily By Mouth and ibruprofen.
Allergies: Allergic to penicillin and cold and dust.
PMHx: Hypertension and type 2 diabetes.
Soc Hx: The patient is married with 2-year-old son. She is a former smoker. She only takes alcohol during social occasions.
Fam Hx: The father are alive with no remarkable health history. His mother has hypertension but it is well controlled. The son is healthy and continuing with period immunizations.
ROS:
GENERAL: 30 pounds of weight gain, alopecia, poor appetite, fatigue, and cold intolerance.
HEENT: Eyes: No vision difficulties, yellow sclerae, or double vision. Ears, Nose, Throat: No hearing difficulties, sneezing, running nose, congestion in the respiratory system, and sore throat.
SKIN: No itching, lesions, and injuries.
CARDIOVASCULAR: No chest pain, edema, chest discomfort or pressure, and palpitations.
RESPIRATORY: No cough, sputum, and shortness of breath.
GASTROINTESTINAL: No diarrhea, abdominal pain, blood in the stool, nausea, or vomiting. The patient reports a low appetite.
GENITOURINARY: Information on the last menstrual period is not available. The patient has no burning sensation during urination.
NEUROLOGICAL: No tingling in extremities, ataxia, dizziness, and headache, or change in bowel movement or bladder control.
MUSCULOSKELETAL: No stiffness of the muscles, pain in the back or joints.
HEMATOLOGIC: No bleeding or bruising. No anemia.
LYMPHATICS: No splenectomy or enlarged nodes.
PSYCHIATRIC: The patient denies she is depressed. The symptoms suggest she is having a mental problem due to sleeplessness and feeling tired.
ENDOCRINOLOGIC: She feels cold all the time. She has no polyuria and polydipsia.
ALLERGIES: Allergic to penicillin and cold and dust.
O.
Physical exam: B/P 120/80, T 98.0F, Pulse rate 78, BMI 20.
Diagnostic results: Thyroid hormonal test, chest X-ray, blood hemoglobin test.
A.
Differential Diagnoses
Hypothyroidism
Hypothyroidism is a condition also known as an underactive thyroid. The condition occurs when the thyroid does not secrete essential hormones for proper functioning (Bekkering et al., 2019). The condition causes some noticeable symptoms including unintentional weight gain, fatigue, dry skin, constipation, and cold sensitivity. Constipation leads to a decrease in the level of appetite (Bekkering et al., 2019). Hypothyroidism is an autoimmune disorder that occurs when antibodies attack the thyroid gland. Treatment involves synthetic thyroid hormone levothyroxine to maintain the required hormone levels in the body. Patients start feeling better after treatment when the severity of the symptoms subside (Bekkering et al., 2019). Patients should talk to a healthcare provider to review their diet since it can affect the recovery process. In the United States, 5 out of 100 people have hypothyroidism which amounts to 4.6 million of the population among people aged 12 years and above.
Hypothyroidism is the most likely condition that the patient is suffering from due to the similarity in the symptoms and the positive results of the thyroid hormonal test.
Iron deficiency anemia
Iron deficiency anemia is a type of anemic condition that results in insufficient red blood cells to carry oxygenated blood to various parts of the body. Lack of sufficient red blood cells leads to symptoms such as exhaustion (Camaschella, 2017). Other symptoms include dizziness, fast heart rate, and shortness of breath. The condition can lead to death or severe health outcomes. Some of the common causes include peptic ulcers, lack of iron in the diet, or colorectal cancer (Camaschella, 2017). Treatment involved iron tablets and iron supplements. Tests for iron deficiency anemia include complete blood count (CBC) (Camaschella, 2017). If the condition is left untreated, it can make a person susceptible to illnesses due to weak immunity. Patients should seek treatment to avoid adverse outcomes.
Obesity
Obesity is a condition that refers to excessive body fat. The disease is not just a cosmetic concern but a medical problem that exposes an individual to various health issues (Bluher, 2019). For example, obese people are at risk of diabetes, high blood pressure, and cancer. Causes include physical inactivity, overeating, genetics, psychological factors, and hypothyroidism (Bluher, 2019). BMI is the standard test to determine if a person is obese. Treatment involves physical activity, change of lifestyle, and regulating the nutrient intake.
Major depressive disorder
Major depressive disorder (MDD) is characterized by a depressive mood that impairs the quality of life. Some of the symptoms of the mental condition involve loss of interest in daily activities, sadness, changes in sleep patterns, appetite, self-esteem, behavior, and energy levels (Hasin et al., 2018). A depressed or irritable mood for two weeks can indicate the presence of MDD. Talk therapy and medication such as serotonin-norepinephrine reuptake inhibitors (SNRIs) are important treatment methods for the condition (Hasin et al., 2018).
Systemic lupus erythema
Systemic lupus erythema (SLE) is an autoimmune condition that affects the skin, kidney, and joints. The major symptoms include fatigue, fever, and joint pain (Zhang et al., 2017). X-rays are essential diagnostic tests to determine the presence of systemic lupus erythema. SLE affects various body organs including the heart, lung, and kidneys (Zhang et al., 2017). Some of the common drugs include non-steroidal anti-inflammatory drugs. The drugs are used to control the symptoms since there is no cure for the disease.

References
Bekkering, G. E., Agoritsas, T., Lytvyn, L., Heen, A. F., Feller, M., Moutzouri, E., … & Farhoumand, P. D. (2019). Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline. Bmj, 365. doi: https://doi.org/10.1136/bmj.l2006
Bluher, M. (2019). Obesity: global epidemiology and pathogenesis. Nature Reviews Endocrinology, 15(5), 288-298. https://doi.org/10.1038/s41574-019-0176-8
Camaschella, C. (2017). New insights into iron deficiency and iron deficiency anemia. Blood reviews, 31(4), 225-233. https://doi.org/10.1016/j.blre.2017.02.004
Hasin, D. S., Sarvet, A. L., Meyers, J. L., Saha, T. D., Ruan, W. J., Stohl, M., & Grant, B. F. (2018). Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry, 75(4), 336-346. doi:10.1001/jamapsychiatry.2017.4602
Zhang, Y. P., Wu, J., Han, Y. F., Shi, Z. R., & Wang, L. (2017). Pathogenesis of cutaneous lupus erythema associated with and without systemic lupus erythema. Autoimmunity Reviews, 16(7), 735-742. https://doi.org/10.1016/j.autrev.2017.05.009

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