SOAP NOTE for 59 year old male annual wellness visit with
COPD and hyperlipidemia
SOAP Note
Subjective
Chief Complaint (CC): “I’m here for my annual wellness visit.”
History of Present Illness (HPI): 59-year-old male presents for annual
wellness visit. He reports overall stable health and requests review of chronic
conditions including COPD and hyperlipidemia. Denies recent COPD
exacerbations, ER visits, or hospitalizations. Reports occasional exertional
dyspnea at baseline with intermittent cough; denies increased sputum
volume/purulence, wheezing, fever, or chest pain. Reports adherence to
inhalers and lipid-lowering therapy without adverse effects. No new acute
complaints.
Past Medical History (PMH): COPD; hyperlipidemia.
Medications: Maintenance inhaler (per medication list); albuterol inhaler
PRN; statin (per medication list).
Allergies: No known drug allergies (NKDA) (patient reports).
Social History: Former smoker (per chart) / tobacco use reviewed and
counseled. Alcohol: occasional (per patient). Denies illicit drug use.
Review of Systems (ROS): Constitutional: Denies fever, chills,
unintentional weight loss. Respiratory: Positive for baseline exertional
dyspnea; denies acute worsening, hemoptysis. Cardiovascular: Denies
chest pain, palpitations, syncope. GI: Denies abdominal pain,
melena/hematochezia. Neuro: Denies focal weakness, dizziness. Psych:
Denies depression symptoms.
1. Annual wellness visit – preventive care and risk assessment
performed.
2. Chronic obstructive pulmonary disease (COPD) – stable by history
today; no acute exacerbation.
3. Hyperlipidemia – chronic; on statin therapy; due for interval
monitoring.
4. Tobacco use history – counseling provided (cessation/reinforcement).
,Plan
COPD:
Continue maintenance inhaler as prescribed; continue albuterol rescue
inhaler PRN.
Review/teach inhaler technique and adherence.
Avoid triggers; reinforce smoke-free environment.
Return precautions reviewed: increased dyspnea, increased sputum
volume/purulence, fever, chest pain, SpO2 decline.
Consider spirometry/pulmonary function testing if not done within
recommended interval or if symptoms change.
Hyperlipidemia:
Continue statin therapy as prescribed.
Order/review lipid panel (and CMP/LFTs as indicated) for medication
monitoring.
Diet/exercise counseling: heart-healthy diet, regular aerobic activity as
tolerated.
Preventive Care / Health Maintenance:
Screenings reviewed and recommended per age/risk: colon cancer
screening if due; prostate cancer screening discussion as appropriate;
diabetes screening; BP monitoring; BMI counseling.
Vaccines reviewed/recommended: annual influenza; COVID booster as
eligible; pneumococcal vaccination due to COPD; shingles (Shingrix) if
not completed; Tdap booster if due.
Health risk assessment addressed: diet, exercise, sleep, fall risk, safety
(seatbelt/home safety), and alcohol use.
Follow-Up: Routine follow-up in 12 months for next wellness visit; sooner for
COPD symptom worsening or to review lab results (typically within 1–4 weeks
depending on completion).
THYROID
,Chief Complaint (CC): "I've been feeling extremely tired and experiencing a
lot of changes lately. My hair is falling out, I'm gaining weight despite not
eating much, and I'm always cold.
History of Present Illness (HPI): A 52-year-old female reports a 6-month
history of worsening fatigue, muscle aches, weakness, and cold intolerance.
There is a 10-pound weight gain despite decreased appetite, along with
increased hair loss and dry skin. The fatigue is described as profound,
affecting daily activities. The patient denies fever, night sweats, or recent
travel.
Review of Systems (ROS): Key reported symptoms include fatigue, weight
gain, cold intolerance, dry skin, hair loss, muscle aches, weakness, joint
stiffness, difficulty concentrating, memory problems, occasional constipation,
irregular and heavy menstrual periods.
Vital Signs: BP 128/82 mmHg, HR 62 bpm, Temp 97.8°F, Wt 165 lbs, Ht 5'4",
BMI 28.3.
General Appearance: Appears fatigued with some periorbital puffiness.
Neck/Thyroid: No visible goiter or nodules.
Skin: Dry, cool, and coarse.
Extremities: Mild nonpitting edema in the lower extremities. Delayed
relaxation of Achilles tendon reflex noted bilaterally.
Labs: TSH 7.5 mIU/L (High), FT4 0.3 ng/dL (Low), FT3 72 ng/dL (Normal).
Assessment:
The patient's symptoms and lab results strongly suggest primary
hypothyroidism. The elevated TSH and low free T4 are consistent with this
diagnosis. Other potential diagnoses like depression and anemia are less
likely given the specific thyroid symptoms but could be considered if
treatment is ineffective. The patient's age and sex are typical for
hypothyroidism. Differential Diagnoses:
Primary Hypothyroidism (ICD-10 E03.9)
Plan:
Medication: Start Levothyroxine 50 mcg daily, taken on an empty stomach
30-60 minutes before breakfast.
Diagnostics:
, Repeat TSH and Free T4 in 6-8 weeks to check response.
Order Thyroid Peroxidase (TPO) antibodies to assess for Hashimoto's
thyroiditis.
Lifestyle Modifications: Recommend a balanced diet, moderate exercise, and
increased fiber intake.
Patient Education: Educate on lifelong Levothyroxine therapy, compliance,
proper timing, potential interactions with food/supplements, and symptoms
of over-replacement.
Follow-up: Schedule a follow-up in 6-8 weeks to review labs and adjust
medication dosage.
THYROID
Chief Complaint (CC): "Check up on my lab results for my thyroid"
History of Present Illness (HPI): MF is seen in the office today for recheck of
thyroid levels. Previous TSH 5.8, T4 6.7, Free T4 1.4. The patient states he
has felt more fatigued X3 months. Denies weight gain or loss. The patient
denies fever, night sweats, or recent travel.
NKA
Medications: Lisinopril 10mg daily, Losartan 50mg daily, Simvastatin 20mg,
Aspirin 81mg daily, iron 325mg daily
Review of Systems (ROS): Key reported symptoms include fatigue
Vital Signs: BP 116/82 mmHg, HR 68 bpm, Temp 97.8°F, Wt 165 lbs, Ht 5'9,
BMI 28.3.
General Appearance: Appears fatigued with some periorbital puffiness.
Neck/Thyroid: No visible goiter or nodules.
Skin: Dry, cool, and coarse.
Extremities: Mild nonpitting edema in the lower extremities.
Labs: Current: TSH 6.9 mIU/L (High), FT4 0.3 ng/dL (Low), FT3 72 ng/dL
(Normal).
COPD and hyperlipidemia
SOAP Note
Subjective
Chief Complaint (CC): “I’m here for my annual wellness visit.”
History of Present Illness (HPI): 59-year-old male presents for annual
wellness visit. He reports overall stable health and requests review of chronic
conditions including COPD and hyperlipidemia. Denies recent COPD
exacerbations, ER visits, or hospitalizations. Reports occasional exertional
dyspnea at baseline with intermittent cough; denies increased sputum
volume/purulence, wheezing, fever, or chest pain. Reports adherence to
inhalers and lipid-lowering therapy without adverse effects. No new acute
complaints.
Past Medical History (PMH): COPD; hyperlipidemia.
Medications: Maintenance inhaler (per medication list); albuterol inhaler
PRN; statin (per medication list).
Allergies: No known drug allergies (NKDA) (patient reports).
Social History: Former smoker (per chart) / tobacco use reviewed and
counseled. Alcohol: occasional (per patient). Denies illicit drug use.
Review of Systems (ROS): Constitutional: Denies fever, chills,
unintentional weight loss. Respiratory: Positive for baseline exertional
dyspnea; denies acute worsening, hemoptysis. Cardiovascular: Denies
chest pain, palpitations, syncope. GI: Denies abdominal pain,
melena/hematochezia. Neuro: Denies focal weakness, dizziness. Psych:
Denies depression symptoms.
1. Annual wellness visit – preventive care and risk assessment
performed.
2. Chronic obstructive pulmonary disease (COPD) – stable by history
today; no acute exacerbation.
3. Hyperlipidemia – chronic; on statin therapy; due for interval
monitoring.
4. Tobacco use history – counseling provided (cessation/reinforcement).
,Plan
COPD:
Continue maintenance inhaler as prescribed; continue albuterol rescue
inhaler PRN.
Review/teach inhaler technique and adherence.
Avoid triggers; reinforce smoke-free environment.
Return precautions reviewed: increased dyspnea, increased sputum
volume/purulence, fever, chest pain, SpO2 decline.
Consider spirometry/pulmonary function testing if not done within
recommended interval or if symptoms change.
Hyperlipidemia:
Continue statin therapy as prescribed.
Order/review lipid panel (and CMP/LFTs as indicated) for medication
monitoring.
Diet/exercise counseling: heart-healthy diet, regular aerobic activity as
tolerated.
Preventive Care / Health Maintenance:
Screenings reviewed and recommended per age/risk: colon cancer
screening if due; prostate cancer screening discussion as appropriate;
diabetes screening; BP monitoring; BMI counseling.
Vaccines reviewed/recommended: annual influenza; COVID booster as
eligible; pneumococcal vaccination due to COPD; shingles (Shingrix) if
not completed; Tdap booster if due.
Health risk assessment addressed: diet, exercise, sleep, fall risk, safety
(seatbelt/home safety), and alcohol use.
Follow-Up: Routine follow-up in 12 months for next wellness visit; sooner for
COPD symptom worsening or to review lab results (typically within 1–4 weeks
depending on completion).
THYROID
,Chief Complaint (CC): "I've been feeling extremely tired and experiencing a
lot of changes lately. My hair is falling out, I'm gaining weight despite not
eating much, and I'm always cold.
History of Present Illness (HPI): A 52-year-old female reports a 6-month
history of worsening fatigue, muscle aches, weakness, and cold intolerance.
There is a 10-pound weight gain despite decreased appetite, along with
increased hair loss and dry skin. The fatigue is described as profound,
affecting daily activities. The patient denies fever, night sweats, or recent
travel.
Review of Systems (ROS): Key reported symptoms include fatigue, weight
gain, cold intolerance, dry skin, hair loss, muscle aches, weakness, joint
stiffness, difficulty concentrating, memory problems, occasional constipation,
irregular and heavy menstrual periods.
Vital Signs: BP 128/82 mmHg, HR 62 bpm, Temp 97.8°F, Wt 165 lbs, Ht 5'4",
BMI 28.3.
General Appearance: Appears fatigued with some periorbital puffiness.
Neck/Thyroid: No visible goiter or nodules.
Skin: Dry, cool, and coarse.
Extremities: Mild nonpitting edema in the lower extremities. Delayed
relaxation of Achilles tendon reflex noted bilaterally.
Labs: TSH 7.5 mIU/L (High), FT4 0.3 ng/dL (Low), FT3 72 ng/dL (Normal).
Assessment:
The patient's symptoms and lab results strongly suggest primary
hypothyroidism. The elevated TSH and low free T4 are consistent with this
diagnosis. Other potential diagnoses like depression and anemia are less
likely given the specific thyroid symptoms but could be considered if
treatment is ineffective. The patient's age and sex are typical for
hypothyroidism. Differential Diagnoses:
Primary Hypothyroidism (ICD-10 E03.9)
Plan:
Medication: Start Levothyroxine 50 mcg daily, taken on an empty stomach
30-60 minutes before breakfast.
Diagnostics:
, Repeat TSH and Free T4 in 6-8 weeks to check response.
Order Thyroid Peroxidase (TPO) antibodies to assess for Hashimoto's
thyroiditis.
Lifestyle Modifications: Recommend a balanced diet, moderate exercise, and
increased fiber intake.
Patient Education: Educate on lifelong Levothyroxine therapy, compliance,
proper timing, potential interactions with food/supplements, and symptoms
of over-replacement.
Follow-up: Schedule a follow-up in 6-8 weeks to review labs and adjust
medication dosage.
THYROID
Chief Complaint (CC): "Check up on my lab results for my thyroid"
History of Present Illness (HPI): MF is seen in the office today for recheck of
thyroid levels. Previous TSH 5.8, T4 6.7, Free T4 1.4. The patient states he
has felt more fatigued X3 months. Denies weight gain or loss. The patient
denies fever, night sweats, or recent travel.
NKA
Medications: Lisinopril 10mg daily, Losartan 50mg daily, Simvastatin 20mg,
Aspirin 81mg daily, iron 325mg daily
Review of Systems (ROS): Key reported symptoms include fatigue
Vital Signs: BP 116/82 mmHg, HR 68 bpm, Temp 97.8°F, Wt 165 lbs, Ht 5'9,
BMI 28.3.
General Appearance: Appears fatigued with some periorbital puffiness.
Neck/Thyroid: No visible goiter or nodules.
Skin: Dry, cool, and coarse.
Extremities: Mild nonpitting edema in the lower extremities.
Labs: Current: TSH 6.9 mIU/L (High), FT4 0.3 ng/dL (Low), FT3 72 ng/dL
(Normal).
