Transgender HRT SOAP

PRESENTING HISTORY/CC: Patient presents to clinic today for transgender hormone therapy management. The patient is a 28-year-old individual assigned female at birth, identifying as male, and uses he/him pronouns. He has been on hormone therapy for 2 years. The patient realized he was transgender at the age of 16. Recent lab findings indicate stable testosterone levels. He has a supportive social network, including family and friends. The patient is interested in full gender transition results. He works as a software engineer and has been seeing a therapist for the past year to support his transition. SUBJECTIVE FINDINGS: - The patient requests a review of his current hormone therapy regimen. - Reports occasional mood swings, which have been present for the past few months. - Mood swings are alleviated by regular exercise and meditation. - No previous episodes of similar symptoms. - Mood swings have a mild impact on daily activities, including work. - No associated symptoms reported. - Recently moved to a new city for work. MED HISTORY AND/OR PRIOR HRT: - Previous hormone therapy began 2 years ago at another clinic. - Past medical history includes anxiety, managed with therapy. - No significant family history relevant to the visit. - Immunizations are up to date. OBJECTIVE FINDINGS: EXAM FINDINGS: General: No acute distress. Calm and cooperative. HEENT: NCAT, Vision/Hearing grossly intact, Swallows without difficulty. No speech impairments. Cardiac: Skin appears well perfused, and is stated as warm and dry. No stated palpitations or CP. Pulm: No obvious externally audible wheezing. Breathing is even and unlabored on room air. No cyanosis noted. No reported SOB. Neuro: A&O x 4. GCS = 15. No reported dizziness or numbness/tingling. Moves all extremities spontaneously. Psych: Appropriate affect. No obvious hallucinations/delusions or stated SI/HI. GI: No obvious visible masses. No c/o N/V/D or abd pain. Integumentary: No visible rashes or jaundice. Genito-Urinary: No stated discomfort. ASSESSMENT & DIAGNOSIS CODES: - F64.9 Gender Dysphoria PLAN FOR CARE & FOLLOW UP: - Continue current hormone therapy regimen. - Schedule follow-up labs in 3 months to monitor hormone levels. - Continue therapy sessions for mental health support. - Next follow-up appointment scheduled for 02/01/2025.