Hypothyroidism SOAP

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Clinical SOAP Note: Hypothyroidism Student’s Name Institutional Affiliation: Clinical SOAP Note: Hypothyroidism Mrs. Reeves is a 67-year-old woman residing in __, __. She is self-referred to the institutions and appears to be a reliable source for her history. Subjective Component Chief Complaint: ‘I feel very weak.’ History of Presenting Complaint: Mrs. Reeves said that she began feeling weak approximately two months before the visit. The weakness affected her performance of daily activities such as household chores. Initially, she would wake up feeling normal with the weakness increasing progressively throughout the day, but as time progressed, she began to wake up feeling weak and fatigued. She did not experience chest pain, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, or palpitations. She did not experience a cough, wheezing, or hemoptysis. Since the weakness began, her appetite has also been decreasing. She claims she can only manage to eat one meal a day only when compelled by her husband. Her skin has been drying progressively although she consumes about four glasses of water every day. She has also been experiencing pain in her elbows and knees which with no aggravating factors but relieved slightly by rest. One month ago, she noticed that her hearing was diminishing slowly – her husband had to shout for her to comprehend his statements. The Patient’s Medical History In her young years, Mrs. Reeves was admitted for mumps at 10 and chicken pox at 13. She has no history of scarlet fever or rheumatic fever. She also suffered a stroke when she was 47 and was admitted and treated successfully with no complications. No history

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