AMY NATUROPATH SOAP & TREATMENT PLAN

SUBJECTIVE The patient, a 45-year-old female, visited the clinic with complaints of persistent fatigue and joint pain over the past three months. She describes the pain as a "dull ache" primarily in her knees and elbows, with severity fluctuating between 4 and 6 on a scale of 10. The symptoms worsen with physical activity and improve slightly with rest. She has attempted self-treatment with over-the-counter pain relievers, which provide minimal relief. The patient reports that the fatigue has progressively worsened, impacting her ability to perform daily activities and work efficiently. She denies any previous episodes of similar symptoms. Associated symptoms include occasional headaches and difficulty sleeping. PAST MEDICAL HISTORY The patient has a history of hypothyroidism, managed with levothyroxine. She underwent an appendectomy at age 30. Her social history reveals a sedentary lifestyle with limited physical exercise. Family history is significant for rheumatoid arthritis in her mother. She is up to date with her immunizations. ALLERGIES Penicillin - Rash SUPPLEMENTS Current: Vitamin D 2000 IU daily, started 1 January 2024 Past: Fish oil 1000 mg daily, started 1 June 2023, discontinued 1 September 2023 PRESCRIPTION MEDICATIONS Current: Levothyroxine 75 mcg daily, started 1 January 2020 Past: Ibuprofen 400 mg as needed, started 1 March 2024, discontinued 1 October 2024 LABS AND INVESTIGATIONS 1 November 2024: Complete Blood Count - Normal 1 November 2024: **Rheumatoid Factor - Elevated (H)** OBJECTIVE NAD Well today Vital signs: Blood pressure 120/80 mmHg, Heart rate 72 bpm Physical examination reveals tenderness in the knees and elbows with mild swelling. No other abnormalities noted. ASSESSMENT Issue 1: Joint pain Assessment: Likely rheumatoid arthritis Investigations planned: Anti-CCP antibody test Treatment planned: Initiate low-dose prednisone Relevant referrals: Rheumatologist PL Past medical conditions include hypothyroidism and appendectomy. PLAN Informed consent obtained Plan for today’s visit includes starting low-dose prednisone and scheduling a follow-up with a rheumatologist. FUTURE PLAN Consider lifestyle modifications to include regular low-impact exercise. Plan to monitor symptoms and adjust treatment as necessary. ACTION ITEMS Order Anti-CCP antibody test Set aside prednisone prescription Send referral to rheumatologist PATIENT ACTION PLAN Dear [patient name], It was wonderful to check in with you. Below is a summary of what we discussed in today’s visit. Thank you for trusting me with your care. Warmly, Dr. Amy Rolfsen NUTRITION Increase intake of anti-inflammatory foods such as leafy greens and fatty fish. SUPPLEMENTS Step 1: Continue Vitamin D 2000 IU daily in the morning for 6 months. MEDICATIONS Prednisone 5 mg daily for 2 weeks, then reassess. LAB TESTING Anti-CCP antibody test REFERRAL Rheumatologist for further evaluation and management NEXT APPOINTMENT Next visit scheduled for 1 December 2024, 25-minute follow-up appointment.