SOAP Note for Hypothyroidism
United State University
Primary Health of Acute Client/Families Across the Lifespan-Clinical Practicum
SOAP Note for Hypothyroidism
ID: Mrs. J B, Age: 50, Race: African American, Gender: Female, Date of Birth: January 15, 1972, Insurance: N/A, Marital Status: Married.
CHIEF COMPLAIN: “I am experiencing fatigue. I want to rest even without working for long. I have increased 7 pounds in 3 months which is causing worry. I experience muscle cramps, and sometimes I get constipation. Nowadays, I can’t tolerate cold weather.”
HISTORY OF THE ILLNESS: A 50 years old African American female patient came to the clinic complaining about fatigue after light tasks. The patient reports gaining weight fast, which is causing a lot of worries to her. The patient works in a restaurant not far away from where she lives. Her job is highly demanding, and she has to keep on walking. The patient disagrees with having seasonal allergies, shortness of breath, chest pains, or frequent headaches.
PAST MEDICAL HISTORY: None
CURRENT MEDICATIONS: None
IMMUNIZATION: The patient is up-to-date with her immunizations.
FAMILY HISTORY: The patient’s father passed away at age 72 and succumbed to throat cancer and memory loss. The patient’s mother died at 68 after suffering from hypertension and depression for three years. The patient has a brother who has a history of stomach ulcers, and he struggles with alcoholism. Her sister is healthy, and she has no known medical history. The patients’ paternal grandmother died at 89 of a stroke resulting from food poisoning. Her paternal grandfather also succumbed to stomach ulcers.
SOCIAL HISTORY: The patient lives with her husband and 1 of their four children. She worked at an airport before switching to a restaurant. The patient admits to being an alcoholic in her 20s but stopped in her early 30s. She claims not to have any experience with hard drugs. The patient is sexually active and only with her husband. She used to go to the gym to maintain her body weight, but the fatigue made her find difficulties exercising. She is a Christian and follows all Christian virtues. The patient enjoys cool music and playing with her last-born son.
REVIEW OF SYSTEMS
GENERAL: The patient reports weight gain and fatigue. She denies a high fever, nocturnal sweats, and a change in appetite.
HAIR, SKIN, AND NAILS: The patient denies rashes, no color changes, no sunburns, and nodes.
HEAD: The patient denies frequent headaches, visual changes, redness, no injury, or drainage.
NECK: The patient does not feel pain or stiffness in the neck—no noted masses or edema.
EYES: No scotomata, no tearing, no pain. The patient has normal vision.
EARS: The patient denies bleeding, having any hearing difficulties, bleeding, tinnitus. No vertigo.
NOSE: Denies nasal obstruction, drainage, or redness
MOUTH & THROAT: The patient denies edema, sore throat, complications absorption, hoarseness, no dental complications, no use of dentures.
CARDIOVASCULAR: The patient doesn’t suffer from peripheral edema, chest pain, or palpitations.
GASTROINTESTINAL: The patient disagrees with having abdominal pain. She disagrees with having nausea, disgorging, or cramps.
ENDOCRINE: The patient has a normal appetite and denies extreme thirst or unconscious prejudice.
LYMPHATICS: The patient has negative tender lymph nodes.
GENITOURINARY: there is an absence of dysuria
MUSCULOSKELETAL: The patient refutes redness and edema to muscles.
NEUROLOGICAL: There are no cognitive or disorientation problems with this patien
PSYCHIATRIC: The patient denies extreme sadness, mood fluctuations, or sleeplessness.
ALLERGIC: no known allergies.
VITAL SIGNS: Temp- 98.9, Pulse- 77, Resp-22, O2- 98% RA, BP- 141/81, weight- 146 lbs., height- 6’.9”, BMI-25.0
GENERAL APPEARANCE: Vigilant, well combed. No acute pains were detected. She is presentable.
HEENT: Normocephalic. Atraumatic. Eyes: PERRLA. No nystagmus bilateral, Pupils are equal, round, and sensitive to light reconciliation. Ears: Bilateral outer ears are normal, free from drainage. Nose: Sputum is midline. No alterations. It is symmetrical, and vessels expound in the mutual snout with transparent drainage.
NECK: Flexible and balanced. No tracheal variation. No goiter noted—no inflamed lymph lumps.
ABDOMEN: The patient has a gentle and non-tender flat belly. There was no inguinal found. No ascites were discovered.
CARDIOVASCULAR: regular S1 & S2, heart rate is standard, no murmurs in a heartbeat.
GENITOURINARY: No wing, suprapubic sympathy, or CVA devotion.
SKIN: Skin is mild and dry. The legs appear dry and darker.
MUSCULOSKELETAL: No joint malformation was noticed. Her spine aroused straight calibration without any curving.
NEUROLOGIC: No cerebellar signs or symptoms, no neural shortfall.
PSYCHIATRIC: Factual to time. Content and appropriate.