SOAP Note (Naturopathy)

Chief Complaints Fatigue and digestive issues. Subjective: John Doe, 45, visits for persistent fatigue and digestive discomfort. - Current problems include fatigue and bloating. - Symptoms have persisted for 3 months, primarily in the afternoon. - Symptoms worsen with stress and improve with rest and a bland diet. - Symptoms have gradually worsened over time. - Previous episodes occurred last year, managed with dietary changes. - Symptoms impact daily activities, causing reduced work productivity. - Associated symptoms include headaches and mild anxiety. Pertinent Information from Side Conversation: - Patient mentioned increased stress at work, contributing to fatigue. Past Medical History Active Allergies - None Active Medications - None Active Supplements - Vitamin D 1000 IU daily - Probiotic 10 billion CFU daily Active Diagnoses - Chronic fatigue syndrome - Irritable bowel syndrome Procedures, Surgeries and Hospitalization - Appendectomy in 2010 Health Care Management: - Last wellness visit: 1 May 2024 - Last Pap date, results: Not applicable - Colonoscopy date and follow up date: 1 January 2023, follow-up in 5 years - Mammogram date and results: Not applicable - Skin cancer screening date: 1 June 2024 - HCV reactivity status: Negative Family History - Mother with hypothyroidism - Father with hypertension Social History - Non-smoker - Occasional alcohol use - Works as a software engineer Review of Systems - Gastrointestinal: Bloating, irregular bowel movements - Neurological: Headaches - Psychiatric: Anxiety - Musculoskeletal: No joint pain - Respiratory: No shortness of breath - Pertinent negatives: No chest pain Objective Physical Examination - Constitutional: Alert, cooperative, NAD, well-developed, and well-nourished. - Neurological Mental Status: Awake & Alert; oriented to person, place & time - Psychiatric: Recent and remote memory intact. - Pt's general behavior, level of consciousness, thought content and emotional status are appropriate and unremarkable. Assessment Evaluation and management services including non-face-to-face time spent on the day of the encounter: • 30 min spent on updates to HPI, vitals, pertinent PE, review of labs, review of meds and supplements, medication management and prescribing and suggested follow up, charting visit Clinical Discussion: 1. Fatigue - Assessment, likely diagnosis for Issue 1: Chronic fatigue syndrome - Treatment planned for Issue 1: Recommend lifestyle modifications including stress management techniques and regular exercise. Consider adaptogenic herbs such as Ashwagandha based on recent studies. 2. Digestive issues - Assessment, likely diagnosis for Issue 2: Irritable bowel syndrome - Treatment planned for Issue 2: Implement a low FODMAP diet and continue probiotic supplementation. Recent research supports the efficacy of probiotics in managing IBS symptoms. Diagnoses - Chronic fatigue syndrome - Irritable bowel syndrome Here is our plan, John! It was great to see you today! Dr. Shah will continue to monitor your progress. Nutrition/Lifestyle: - Implement a low FODMAP diet - Practice daily stress management techniques Supplements: Continue - Vitamin D 1000 IU daily - Probiotic 10 billion CFU daily Add - Ashwagandha 500 mg daily Follow up labs - Return for follow-up labs in 3 months and review results 2 weeks later.