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With the above information, construct the subjective and objective data in a SOAP Note format.
Subjective:
C.C: Patient presents with fatigue, concentration difficulty, changes in appetite, constipation, and weight gain: Sleepiness and low mood.
HPI: Patient highlights that the symptoms have been present for six weeks. She believes that something is wrong with her.
PMH: No history of psychiatric treatment.
ROS:
Constitutional: Reports fatigue and feeling down and sleepy.
Gastrointestinal: Reports constipation
Genitourinary: Reports irregular menstrual cycle
Psych: Reports difficulty with concentration and decreased mood. The patient denies suicidal ideation.
Objective:
V.S: Wt 155 lbs
Constitutional: Displays sluggish gait and is slow to respond (Brigham et al., 2023).
HEENT: Thinning hair
Integumentary: Dry skin
Neurological: Clear speech with a blunted effect
Psych: Patient is alert and oriented, with clear speech.
Is there any other information you would obtain to assist you in determining treatment options?
Obtaining additional information regarding the patient’s condition is essential to ensure an accurate diagnosis. The information that should be gathered includes any possibility of over-the-counter medication, the patient’s diet, surgical and family history, and possible aggressors. Factors that affect patient health, such as the social and financial environment, should be assessed (Jensen & Smock, 2022). Additional information to be gathered includes the patient’s vital signs, sleep patterns, and health promotion behaviors. While this information is part of the patient’s assessment, obtaining the necessary details will eliminate any alternative diagnosis and facilitate the establishment of a treatment plan.
Discuss the top three differential diagnoses.
Three differential diagnoses for this patient may include major depressive disorder (MDD), perimenopause, and hypothyroidism. MDD is characterized by the patient’s fatigue, feeling “down in the dumps,†and weight gain. This can be coupled by feelings of hopelessness and emptiness, lack of motivation, and low self-worth (Slopien et al., 2020). Perimenopause refers to the condition and period in which the body makes a transition to menopause or the final menstrual cycle. This is often characterized by changes in mood, trouble sleeping, irregular periods, and trouble concentrating. Hypothyroidism occurs when the thyroid gland fails to produce ample thyroid hormone. It is characterized by fatigue, weight gain, dry skin, and irregular menstrual periods.
What initial diagnostics would you order?
Initial diagnostics that should be ordered for this patient include a complete blood count with differential, TFTs, Vitamin D, comprehensive metabolic panel (CMP), and TSH. The patient should also be screened for MDD using the PHQ-9 test.
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