Annotated Soap Note Hair Loss

Topics: Low-carbohydrate diet, Noncicatricial alopecia, Obesity Pages: 5 (1732 words) Published: May 30, 2013
Chief complaint: hair loss that started several months ago.

History of Present Illness
This 45 year old female presents with:
1. Hair loss
The patient presents with hair loss that began 5 months ago. The problem is mild to moderate and has worsened. The initial location of hair loss was the diffuse scalp and temporal region that occurred gradually. Symptoms are associated with very low carbohydrate dieting and new medication within 3 - 6 months (Aleve). Symptoms are not associated with hair pulling, increased psychological stress, fever, recent illness, recent surgery or scalp rash. Relevant history positive for family history of hair thinning on both sides. Relevant history negative for anemia, hyperthyroidism, hypothyroidism, rheumatoid arthritis, vitiligo or ulcerative colitis. The patient is not currently pregnant. Associated symptoms include intentional weight loss of 50 lbs over 10 months. Pertinent negatives include anxiety, depression, dry scalp, fever, heat intolerance, itchy scalp, rash, scalp kerion, scalp tenderness or skin sores. Noticed hair thinning for about 5 months. No bald spots, lesions on scalp or skin. Estimates she has lost 25% of hair thickness.

Chronic Problems
Past Medical/Surgical History
1996 (R) Shoulder arthroscopy

Obstetric History
G1P1. Not pregnant.

Family History
Disease Detail Family Member Age Cardiomyopathy Father67 (cause of death)
Cancer -lungMother59 (cause of death)

Social History
Employment: Property Management, no exposure to chemicals.
Marital Status / Family: Currently single, previously divorced once, not in relationship since divorce. Has an 11-year-old daughter. Tobacco: Never smoked.
Alcohol: Occasional beer.
Caffeine: coffee- 3 cups a day.
Lifestyle: Moderate activity level. Exercises 3-4 days per week and takes care of horses daily. Medications (Active)
Medication Name
Mirena IUD, placed in 2012.
Aleve as needed, taking several times a week over winter.
Allergies: NKANo Known Drug Allergies
Review of Systems
Positive for: Weight loss. Has been following a very low carb diet and has lost 50 lbs. since July. No protein, nonstarchy vegetable or calorie restriction. Negative: fever and night sweats.
Respiratory: Negative: cough, dyspnea.
Cardiovascular: Negative: chest pain and irregular heartbeat/palpitations. Gastrointestinal: Negative: abdominal pain, constipation and diarrhea. Genitourinary: The patient is pre-menopausal. No menses with IUD. Negative: dysuria.

Metabolic/Endocrine: Positive for hair loss, see HPI. Weight loss from diet and lifestyle changes. Negative: heat or cold intolerance.
Neuro/Psychiatric: Negative: anxiety and depression.
Negative: extremity weakness, headache and numbness or weakness in extremities. Dermatologic: No hirsutism or signs of virilization, nail changes, rash, or skin sores. Scalp without pruritus, burning, or lesions. No new hair products. Shampoos daily. No chemical hair treatments. No hair loss on other parts of body. Hair lost has roots, no hair breakage. Does not put hair into braids or ponytails on regular basis. See Chief Complaint and HPI.

Musculoskeletal: Negative: joint pain and joint swelling.
Hematology: Negative: easy bleeding, bruising or history of anemia. Vital Signs.
Height: 5’8”
Weight: 237
BMI: 36
Blood Pressure: 130/75
Pulse: 80

Physical Exam
Constitutional: Well developed, no distress.
Eyes: PERRLA, no injection, bilaterally.
Neck / Thyroid: Symmetric, trachea midline and mobile. No thyromegaly or thyroid nodules. Lymphatic: No cervical or supraclavicular adenopathy.
Respiratory: Chest symmetric. Lungs clear to auscultation. Respiratory effort is normal. Cardiovascular: Regular rate and rhythm with normal S1, S2. No murmur or rub. Abdomen: Nontender. No masses or organomegaly, exam limited by obesity. No bruits. Integumentary:...
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