SOAP Note Fin

Identifying Data

Patient is a 56-year-old female who is an office manager and is married

Source and Reliability

The patient is the historian and is trustworthy

Subjective

Chief Complaint

"I have been feeling extremely tired in the last three months, and I have been adding weight despite eating less."

History of Present Illness

The patient complains of gradual fatigue in the last three months that has been interrupting her daily functioning. She even talks of experiencing exhaustion after a complete night's rest. It does not end throughout the day and is aggravated in the afternoons. She has gained about 15 pounds despite the decrease in her caloric consumption and efforts to exercise. She mentions that she has become sensitive to cold and needs additional layers of clothing even in hot conditions. The patient reports that she has regular constipation 2-3 times a week, which is not a regular occurrence. She denies any chest pain, palpitations, shortness of breath, or dizziness. She has observed that her hair is thinning, and she feels dry skin. No relieving factors have been identified. The symptoms gradually increase and have a serious effect on her performance at work and social life.

Medications

• Lisinopril 10 mg PO (by mouth) daily, last dose taken this morning at 7:00 AM for hypertension
• Atorvastatin 20 mg PO (by mouth) daily, last dose taken this morning at 7:00 AM for hyperlipidemia
• Multivitamin PO (by mouth) daily, last dose taken this morning at 7:00 AM
• No OTC medications/ herbal supplements

Past Medical History

Allergies: No known drug, food, or environmental allergies

Childhood Illnesses: Chickenpox at age 7, denies rheumatic fever, measles, mumps, or rubella.

Adult Illnesses: Hypertension diagnosed 5 years ago, hyperlipidemia diagnosed 3 years ago

Injuries: None significant

Surgeries: Appendectomy when she was 23 years old.

Hospitalizations: Childbirth alone

Obstetric/Gynecologic: G2P2, last menstrual period 14 months ago, currently postmenopausal

Psychiatric: Denies history of mental health disorders

Health Maintenance: The last physical examination was 18 months ago

Immunizations: Up to date with Tdap, MMR (received in childhood), Hepatitis B series completed in adulthood, Polio series completed in childhood, influenza vaccine received 2 months ago, COVID-19 vaccinations current, received Pneumovax at age 50

Dental Exams: Currently getting annual checkups, most recent checkup 6 months ago with regular cleaning

Last Eye Exam: 1 year ago, wears reading glasses for presbyopia

Last Pap/GYN: 10 months since, normal outcome

Self-Breast Exam (SBE): Patient performs monthly self-breast exams, last exam 2 weeks ago with no abnormalities noted

Family History

Mother is 78 years old with a history of hypothyroidism and type 2 diabetes. Father passed away at 72 years old due to a myocardial infarction. One 53-year-old sister has Hashimoto's thyroiditis. Maternal grandmother had thyroid disease. No family history of cancer or autoimmune diseases other than thyroid disease. (See genogram below)

Personal and Social History

College graduate working as an office manager. Married for 30 years with two adult children. Likes reading and gardening, and has minimized these activities because of tiredness. Previously walked 30 minutes daily, but now struggles with energy for exercise. Diet is comprised of balanced food containing vegetables, lean protein foods, and whole grains. Denies tobacco use, alcohol use, no more than occasional wine with dinner, and denies recreational drug use. Patient is independent in all ADLs such as bathing, dressing, toileting, transferring, continence, and feeding. The patient is also independent in all iADLs, such as managing finances, shopping, meal preparation, housekeeping, transportation, and medication management, although she notes reduced energy, influencing efficiency in these areas.

Review of Systems

General: Fatigue, weight gain, cold intolerance

Eyes: Denies vision changes, eye pain, or discharge

Ears/Nose/Throat: Denies hearing loss, tinnitus, sore throat, or nasal congestion

Endocrine: Denies heat intolerance, excessive thirst, or polyuria, reports the above-mentioned symptoms.

Cardiovascular: Denies chest pain, palpitations, or orthopnea.

Respiratory: Denies cough, shortness of breath, or wheezing

Gastrointestinal: Constipation as noted, denies nausea, vomiting, diarrhea, or abdominal pain

Genitourinary: Denies dysuria, frequency, or urgency

Hematology/Lymph: Denies easy bruising, bleeding, or lymph node swelling

Integumentary: Dry skin, hair thinning

Neck: Denies neck swelling or pain

Neurological: Denies headache, dizziness, weakness, or numbness

Musculoskeletal: Reports generalized muscle aches, denies joint pain or stiffness

Psychological: Reports feeling discouraged about symptoms but denies depression or anxiety

Objective

Vital Signs

• BP: 138/86 mmHg
• Temperature: 97.2°F
• Pulse: 58 bpm
• Respirations: 14 per minute
• Height: 5'5"
• Weight: 172 lbs
• BMI: 28.6 (overweight)

Physical Examination

General: Well-groomed, alert-looking female appearing stated age, mildly fatigued

Eyes: Pupils are equal, round, and reactive to light, conjunctiva is clear, and there is mild periorbital puffiness

Ears/Nose/Throat: Tympanic membranes intact, oropharynx without erythema or exudate

Endocrine: Thyroid gland mildly enlarged, smooth, nontender, no nodules palpated

Cardiovascular: Regular rate and rhythm, bradycardic, no murmurs, rubs, or gallops, peripheral pulses 2+ bilaterally

Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi

Gastrointestinal: Abdomen soft, nontender, nondistended, bowel sounds present in all quadrants

Genitourinary: Deferred

Hematology/Lymph: No lymphadenopathy appreciated

Integumentary: Skin cool and dry, mild pallor noted

Neck: Full range of motion, no JVD

Neurological: Alert and oriented x3, cranial nerves II-XII intact, reflexes delayed, 1+ deep tendon reflexes

Musculoskeletal: Normal gait, full range of motion in all extremities

Psychological: Affect appropriate, mood appears slightly discouraged

Assessment and Plan

Differential Diagnoses

1. 1. Hypothyroidism (E03.9): The patient has classic symptoms, which include fatigue, weight gain, cold intolerance, constipation, dry skin, loss of hair, and bradycardia. Hypothyroidism is found in about 5% of the general population, where the prevalence is higher among women above 50 years old (Ametepe et al., 2025). Thyroid enlargement and slow reflexes are characteristic features of the physical examination. Her family history of thyroid disease is very strong, with the mother having hypothyroidism and the sister having Hashimoto thyroiditis, which is an important risk factor. Individuals whose first-degree relative had an autoimmune thyroid disease are at a considerable risk of getting the disease (Bujnis et al., 2025). Relevant positives are fatigue, increased weight with reduction in intake, cold intolerance, constipation, bradycardia, skin parchment, delayed reflex time, and family history. Pertinent negatives are the lack of chest pains and a normal cardiovascular examination otherwise.

1. 2. Depression (F32.9): Major depressive disorder might manifest itself through fatigue, change of weight, and loss of interest in activities. Nevertheless, the patient denies feelings of hopelessness, anhedonia, or suicidal thoughts. Depression alone does not explain the physical findings of bradycardia, slow reflexes, enlarged thyroid, and cold intolerance. Although she claims that she is discouraged by her symptoms, this does not seem to be a primary mood disorder but more of a reactive one.

1. 3. Anemia (D64.9): Fatigue and pallor may indicate anemia. Nevertheless, the patient does not report any easy bruising, bleeding, or other hematologic symptoms. The combination of symptoms, such as cold intolerance, constipation, weight gain, and delayed reflexes, is not characteristic of isolated anemia.

1. 4. Chronic Fatigue Syndrome (G93.3): Although fatigue is the most common complaint, chronic fatigue syndrome is usually accompanied by post-exertional malaise and does not explain the weight gain, cold intolerance, bradycardia, or delayed reflexes seen in this patient.

Most Likely Diagnosis: Primary Hypothyroidism (E03.9)

Pathophysiology: Primary hypothyroidism is caused by a lack of production of adequate thyroid hormones by the thyroid gland. In developed nations, the most prevalent etiology is Hashimoto's thyroiditis, which is an autoimmune disease in which the body responds by attacking thyroid tissue (Vargas-Uricoechea et al., 2025). The lowered level of thyroid hormones results in a low level of metabolism in all parts of the body, and this is the reason why the patient experiences the symptoms of decreased energy, weight gain, and intolerance to cold. Metabolism, heart activity, bowel movement, and brain reflexes are regulated by the thyroid hormones. Lipid metabolism is also impacted by hormonal deficiency, which tends to aggravate existing hyperlipidemia and increase cardiovascular risk (Rodolfi et al., 2025).

Diagnostic Testing: The first laboratory testing would be thyroid-stimulating hormone (TSH) and free thyroxine (T4). High TSH with low-free T4 is evidence of primary hypothyroidism. To identify Hashimoto's thyroiditis, Thyroid peroxidase antibodies (TPO) should be determined. A complete blood count will eliminate anemia as a diagnosis. The lipid profile must be received because hypothyroidism exacerbates hyperlipidemia (Kotak et al., 2024). Radiology testing, such as thyroid ultrasound, is not indicated at this time due to the absence of thyroid nodules observed in the physical check. Cardiac testing (ECG or echocardiography) is not indicated because the patient does not experience any chest pain or cardiac symptoms other than bradycardia, which is expected with hypothyroidism. Neurologic testing is also not indicated because the delayed reflexes are consistent with hypothyroidism.

Medications and Treatments: Levothyroxine is given as the first-line treatment of hypothyroidism as recommended by the American Thyroid Association (Eldeiry et al., 2025). The initial dose is normally 1.6 mcg/kg body weight per day, on an empty stomach. In the case of this patient, the initial dose would be about 75-100 mcg PO (by mouth) daily, to be taken lifelong as this is a chronic condition requiring continuous thyroid hormone replacement therapy. TSH is to be rechecked after 6-8 weeks with the necessary alterations of dose to maintain the TSH at a range of 0.5-2.5 mIU/L. The patients should be informed about the need to take levothyroxine regularly and avoid calcium and iron supplements within the 4-hour period of TSH measurement. The non-pharmacological approach involves routine exercise, a high-fiber diet to treat constipation, and proper hydration (Hassan et al., 2025). Monitoring of atorvastatin and lisinopril that the patient already takes should be continued, as thyroid replacement can influence the conditions.

Evaluations: Physical therapy, occupational therapy, and speech therapy evaluations are not indicated at this moment. Mental health assessment is not indicated because the symptoms of mood states in the patient seem to be a reaction to her physical condition instead of a significant psychiatric disorder.

Motivational Interviewing: I would use the motivational interviewing techniques to discuss with the patient what she knows about the hypothyroidism and concerns about the lifetime use of medication. Highlighting the fact that treatment usually leads to total elimination of symptoms in a few weeks is a way of improving adherence. Motivation during the initiation of treatment may be ensured by setting small achievable goals, like resuming daily walks as one gains more energy.