SOAP Note for Hypothyroidism
Student Name
Program Name, Institution
Course Name
Instructor Name
Date…..
Page 1 of 6
, SOAP Note for Hypothyroidism
Patients name: Tobias
Shrute Age: 59 D.O.B:
18/10/1969
Gender: M
SUBJECTIVE DATA
Chief Complaint (CC): "over the last three months, I've been feeling exhausted. I gained 4
pounds of weight, which is scary. I find it difficult to deal with coldness, felt muscle cramps as
well as constipation for nearly 1 month. ".
History of Present Illness (HPI): He has been feeling exhausted almost all of the time
throughout the last month. He's still feeling chilly in the mornings and evenings. He had back
problems and stomach cramps, and she had gained some weight contrary to her desires. The
signs are of a slow onset, not exacerbated by anything or improved by anything.
Medications: He's a diabetic. Insulin subcutaneous twice per day.
Allergies: No allergies to medications, allergic to eggs.
Past Medical History (PMH): He has a history of hospital admission when he was 30 years old
because of diabetes and no blood transfusions.
Current medication: Insulin for diabetes management.
Past Surgical History (PSH): no surgical history
Family History: He's a father; his children are alive and well. His wife died of hypertension. His
parents are deceased; mother due to a heart attack, a father due to hypothyroidism.
Immunization: He says he's received all of the vaccinations.
Page 2 of 6
Student Name
Program Name, Institution
Course Name
Instructor Name
Date…..
Page 1 of 6
, SOAP Note for Hypothyroidism
Patients name: Tobias
Shrute Age: 59 D.O.B:
18/10/1969
Gender: M
SUBJECTIVE DATA
Chief Complaint (CC): "over the last three months, I've been feeling exhausted. I gained 4
pounds of weight, which is scary. I find it difficult to deal with coldness, felt muscle cramps as
well as constipation for nearly 1 month. ".
History of Present Illness (HPI): He has been feeling exhausted almost all of the time
throughout the last month. He's still feeling chilly in the mornings and evenings. He had back
problems and stomach cramps, and she had gained some weight contrary to her desires. The
signs are of a slow onset, not exacerbated by anything or improved by anything.
Medications: He's a diabetic. Insulin subcutaneous twice per day.
Allergies: No allergies to medications, allergic to eggs.
Past Medical History (PMH): He has a history of hospital admission when he was 30 years old
because of diabetes and no blood transfusions.
Current medication: Insulin for diabetes management.
Past Surgical History (PSH): no surgical history
Family History: He's a father; his children are alive and well. His wife died of hypertension. His
parents are deceased; mother due to a heart attack, a father due to hypothyroidism.
Immunization: He says he's received all of the vaccinations.
Page 2 of 6
