Functional Medicine SOAP note

Subjective Notes: Date: 2023-10-15 Patient consulting reason: Chronic fatigue and digestive issues Detailed patient history including presenting complaints, past medical history, current medications, and relevant symptoms: The patient, a 45-year-old female, presents with chronic fatigue and bloating. She has a history of hypothyroidism and IBS. Current medications include Levothyroxine 75 mcg orally once daily. Current medications: - Levothyroxine 75 mcg orally once daily Vitals: - Weight: 150 lbs - Height: 5'6" - BMI: 24.2 Objective Notes: General physical examination findings: The patient appears tired but is in no acute distress. Skin is warm and dry. Cardiovascular examination findings: Heart rate is regular, no murmurs detected. Respiratory examination findings: Lungs are clear to auscultation bilaterally. Neurological examination findings: Cranial nerves II-XII are intact, reflexes are normal. Notable Labs: Date of labs: 2023-10-10 - TSH: 2.5 mIU/L - Free T4: 1.1 ng/dL - Vitamin D: 20 ng/mL (low) Assessment Section: Notes - - Hypothyroidism - Irritable Bowel Syndrome (IBS) - Vitamin D deficiency Practitioner Recommendations: For each condition: Condition name: Hypothyroidism Medication/Treatment name: Levothyroxine Dose: Continue 75 mcg orally once daily Side Effects/Expectations: Monitor for symptoms of hyperthyroidism Patient Decision: Agrees to continue current dosage Recheck Labs: TSH and Free T4 in 6 weeks Condition name: IBS Medication/Treatment name: Probiotic Dose: One capsule daily Side Effects/Expectations: May improve bloating and digestive health Patient Decision: Agrees to start probiotic Recheck Labs: None Condition name: Vitamin D deficiency Medication/Treatment name: Vitamin D3 supplement Dose: 2000 IU daily Side Effects/Expectations: Improve energy levels and bone health Patient Decision: Agrees to start supplementation Recheck Labs: Vitamin D level in 3 months Lifestyle: Diet recommendations: Increase fiber intake, reduce processed foods Exercise recommendations: 30 minutes of moderate exercise 5 times a week Stress management recommendations: Practice mindfulness meditation daily Patient Decision: Summary of patient's decisions regarding treatments and medications: The patient agrees to continue Levothyroxine, start a probiotic, and begin Vitamin D supplementation. She is committed to dietary changes and stress management practices. Follow-up: Follow-up instructions for various aspects of care: Return visit in 6 weeks for thyroid function tests Emergency instructions: Contact the clinic if experiencing symptoms of hyperthyroidism or severe abdominal pain.