Episodic/Centered SOAP Be aware
Pupil’s Identify
Institutional Affiliation
Course
Professor’s Identify
Date
Episodic/Centered SOAP Be aware
Affected person Data:
Initials: C, Age: 32, Intercourse: Feminine, Race: White
S.
CC: I have been feeling exhausted and my hair is falling out.
HPI: Chantal, a 32-year-old feminine affected person presents to the well being facility complaining of exhaustion and hair falling out. She has skilled an unintentional weight achieve of 30 kilos for the final one yr and low urge for food. The affected person has been experiencing chilly intolerance and sleeplessness. She denied being depressed and enjoys numerous hobbies.
Present Medicines: Nutritional vitamins (Ls)Meloxicam Oral 15 Mg 1 Tab(S) Every day By Mouth and ibruprofen.
Allergy symptoms: Allergic to penicillin and chilly and mud.
PMHx: Hypertension and sort 2 diabetes.
Soc Hx: The affected person is married with 2-year-old son. She is a former smoker. She solely takes alcohol throughout social events.
Fam Hx: The daddy are alive with no exceptional well being historical past. His mom has hypertension but it surely is nicely managed. The son is wholesome and persevering with with interval immunizations.
ROS:
GENERAL: 30 kilos of weight achieve, alopecia, poor urge for food, fatigue, and chilly intolerance.
HEENT: Eyes: No imaginative and prescient difficulties, yellow sclerae, or double imaginative and prescient. Ears, Nostril, Throat: No listening to difficulties, sneezing, operating nostril, congestion within the respiratory system, and sore throat.
SKIN: No itching, lesions, and accidents.
CARDIOVASCULAR: No chest ache, edema, chest discomfort or strain, and palpitations.
RESPIRATORY: No cough, sputum, and shortness of breath.
GASTROINTESTINAL: No diarrhea, belly ache, blood within the stool, nausea, or vomiting. The affected person stories a low urge for food.
GENITOURINARY: Data on the final menstrual interval is not out there. The affected person has no burning sensation throughout urination.
NEUROLOGICAL: No tingling in extremities, ataxia, dizziness, and headache, or change in bowel motion or bladder management.
MUSCULOSKELETAL: No stiffness of the muscle tissue, ache within the again or joints.
HEMATOLOGIC: No bleeding or bruising. No anemia.
LYMPHATICS: No splenectomy or enlarged nodes.
PSYCHIATRIC: The affected person denies she is depressed. The signs recommend she is having a psychological downside attributable to sleeplessness and feeling drained.
ENDOCRINOLOGIC: She feels chilly on a regular basis. She has no polyuria and polydipsia.
ALLERGIES: Allergic to penicillin and chilly and mud.
O.
Bodily examination: B/P 120/80, T 98.0F, Pulse charge 78, BMI 20.
Diagnostic outcomes: Thyroid hormonal take a look at, chest X-ray, blood hemoglobin take a look at.
A.
Differential Diagnoses
Hypothyroidism
Hypothyroidism is a situation often known as an underactive thyroid. The situation happens when the thyroid doesn’t secrete important hormones for correct functioning (Bekkering et al., 2019). The situation causes some noticeable signs together with unintentional weight achieve, fatigue, dry pores and skin, constipation, and chilly sensitivity. Constipation results in a lower within the stage of urge for food (Bekkering et al., 2019). Hypothyroidism is an autoimmune dysfunction that happens when antibodies assault the thyroid gland. Remedy entails artificial thyroid hormone levothyroxine to keep up the required hormone ranges within the physique. Sufferers begin feeling higher after therapy when the severity of the signs subside (Bekkering et al., 2019). Sufferers ought to speak to a healthcare supplier to assessment their weight loss program since it could possibly have an effect on the restoration course of. In america, 5 out of 100 folks have hypothyroidism which quantities to four.6 million of the inhabitants amongst folks aged 12 years and above.
Hypothyroidism is the probably situation that the affected person is affected by as a result of similarity within the signs and the optimistic outcomes of the thyroid hormonal take a look at.
Iron deficiency anemia
Iron deficiency anemia is a kind of anemic situation that ends in inadequate purple blood cells to hold oxygenated blood to varied elements of the physique. Lack of ample purple blood cells results in signs similar to exhaustion (Camaschella, 2017). Different signs embody dizziness, quick coronary heart charge, and shortness of breath. The situation can result in dying or extreme well being outcomes. A few of the widespread causes embody peptic ulcers, lack of iron within the weight loss program, or colorectal most cancers (Camaschella, 2017). Remedy concerned iron tablets and iron dietary supplements. Assessments for iron deficiency anemia embody full blood depend (CBC) (Camaschella, 2017). If the situation is left untreated, it could possibly make an individual inclined to sicknesses attributable to weak immunity. Sufferers ought to search therapy to keep away from opposed outcomes.
Weight problems
Weight problems is a situation that refers to extreme physique fats. The illness is not only a beauty concern however a medical downside that exposes a person to varied well being points (Bluher, 2019). For instance, overweight persons are prone to diabetes, hypertension, and most cancers. Causes embody bodily inactivity, overeating, genetics, psychological components, and hypothyroidism (Bluher, 2019). BMI is the usual take a look at to find out if an individual is overweight. Remedy entails bodily exercise, change of way of life, and regulating the nutrient consumption.
Main depressive dysfunction
Main depressive dysfunction (MDD) is characterised by a depressive temper that impairs the standard of life. A few of the signs of the psychological situation contain lack of curiosity in every day actions, disappointment, modifications in sleep patterns, urge for food, vanity, habits, and power ranges (Hasin et al., 2018). A depressed or irritable temper for 2 weeks can point out the presence of MDD. Discuss remedy and treatment similar to serotonin-norepinephrine reuptake inhibitors (SNRIs) are essential therapy strategies for the situation (Hasin et al., 2018).
Systemic lupus erythema
Systemic lupus erythema (SLE) is an autoimmune situation that impacts the pores and skin, kidney, and joints. The foremost signs embody fatigue, fever, and joint ache (Zhang et al., 2017). X-rays are important diagnostic assessments to find out the presence of systemic lupus erythema. SLE impacts numerous physique organs together with the center, lung, and kidneys (Zhang et al., 2017). A few of the widespread medication embody non-steroidal anti-inflammatory medication. The medication are used to regulate the signs since there is no remedy for the illness.
References
Bekkering, G. E., Agoritsas, T., Lytvyn, L., Heen, A. F., Feller, M., Moutzouri, E., … & Farhoumand, P. D. (2019). Thyroid hormones therapy for subclinical hypothyroidism: a medical follow guideline. Bmj, 365. doi: https://doi.org/10.1136/bmj.l2006
Bluher, M. (2019). Weight problems: international epidemiology and pathogenesis. Nature Assessments Endocrinology, 15(5), 288-298. https://doi.org/10.1038/s41574-019-0176-Eight
Camaschella, C. (2017). New insights into iron deficiency and iron deficiency anemia. Blood Assessments, 31(four), 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 grownup DSM-5 main depressive dysfunction and its specifiers in america. JAMA Psychiatry, 75(four), 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 related to and with out systemic lupus erythema. Autoimmunity Assessments, 16(7), 735-742. https://doi.org/10.1016/j.autrev.2017.05.009
