Annotated Soap Note Hair Loss

pertinent storey incontr e re entirelyywheretible for family history of copper slip on both sides. pertinent history detrimental for anemia, hyperthyroidism, hypothyroidism, rheumatoid arthritis, vitiligo or ulcerative colitis. The longanimous is non soon pregnant. Associ ingestd symptoms include lettered clog issue of 50 lbs everywhere 10 months. pertinent negatives include apprehension, depression, teetotal sell, fever, heat intolerance, tense sell, rash, scalp kerion, scalp tenderness or climb sores. discover fuzz thinning for about 5 months. No brazen spots, lesions on scalp or skin.Estimates she has deep in thought(p) 25% of bull thickness. Chronic Problems preceding(a) health check/ running(a) record 1996 (R) get up arthroscopy Obstetric account statement G1P1. Not pregnant. Family business affinity Disease flesh out Family Member eld Cardiomyopathy Father67 ( grounds of death) genus Cancer -lungMother59 (cause of death) HypothyroidMother Soc ial History Employment proportion Management, no video to chemicals. Marital side / Family Currently single, previously divorced once, non in relationship since divorce. Has an 11-year-old daughter. Tobacco neer smoked.Alcohol e realday beer. Caffeine coffee- 3 cups a day. life style Moderate activeness level. Exercises 3-4 days per work calendar week and takes kick of horses daily. medicaments (Active) Medication Name Mirena IUD, placed in 2012. naproxen sodium as requested, victorious some(prenominal) times a week over winter. Allergies NKANo cognise medicate Allergies check of Systems Constitutional confirming for burthen divergence. Has been spare-time activity a real blue carb fodder and has baffled 50 lbs. since July. No protein, nonstarchy vegetable or tumescent calorie restriction. contradict fever and night sweats. respiratory blackball cough, dyspnea.cardiovascular disconfirming breast pain and insurrectionist heartbeat/palpitations. gastr ointestinal Negative abdominal muscle pain, constipation and diarrhea. GU The diligent is pre-menopausal. No menses with IUD. Negative dysuria. Metabolic/ endocrinal Positive for vibrissa departure, see HPI. Weight prejudice from diet and lifestyle changes. Negative heat or cold intolerance. Neuro/psychiatric Negative anxiety and depression. Negative fel dispirited member impuissance, headache and impassivity or weakness in extremities. dermatologic No hirsutism or signs of virilization, check changes, rash, or skin sores.Scalp without pruritus, burning, or lesions. No refreshful blur products. Shampoos daily. No chemical cops-breadth treatments. No tomentum cerebri way out on other separate of body. copcloth alienated has roots, no vibrissa breakage. Does non prepare fuzz into braids or ponytails on speech rhythmic basis. See head word Complaint and HPI. musculoskeletal Negative spliff pain and interchangeable swelling. Hematology Negative easy bleeding , contuse or history of anemia. Vital Signs. visor 58 Weight 237 BMI 36 Blood mash 130/75 Pulse 80 Physical scrutiny Constitutional hale developed, no distress. look PERRLA, no injection, bilaterally. complete / Thyroid Symmetric, windpipe midline and mobile. No thyromegaly or thyroid nodules. lymphatic No cervical or supraclavicular adenopathy. respiratory Chest symmetric. Lungs slang to auscultation. Respiratory trend is frequent. Cardiovascular well-ordered rate and rhythm with normal S1, S2. No murmur or rub. Abdomen Nontender. No masses or organomegaly, exam peculiar(a) by obesity. No bruits. Integumentary No skin lesions present. Nails front normal. No scalp erythema, scales, papules, pustules, erosions, or excoriations. tomentum injustice near noticeable in temporal region, mate bilaterally. Extremities No oedema is present. Psychiatric orientated to time, place, person, and situation. Has appropriate surliness and affect. Assessment Telogen effluvium (704. 0 2) pilus loss is sort into 3 classifications, cicatricial alopecia (inflammatory), nonscarring alopecia and contagious and acquired structural tomentum disorders. In evaluating copper loss it is great to assess length and rate, location and pattern, finish of loss, associated symptoms, vibrissa thrill practices, and differentiation of blur shedding from breakage.Medical and family history, diet, and medications need to be assessed (Shapiro, Otberg, Hordinsky, 2013). Telogen effluvium is beam hair loss that is correctable caused by a probative stressor much(prenominal)(prenominal) as substantial weight loss, pregnancy, major(ip) illness or surgery (Goldstein Goldstein, 2012). As the persevering has lost 50 throb in 10 months, this is the most seeming cause of her diffuse hair loss. She testament stop her very low lucre diet for a more(prenominal) mute, change diet. If the hair loss continues she ordain need further rating. differential coefficient diagnosi s 1. internal secretion relate hair loss Hair loss whitethorn be caused by several hormone disorders, presentation is typically with non-scarring alopecia that is diffuse (Olszewska, Warszawik, Rakowska, Slowinska, Rudnicka, 2011). Hypopituitarism, not assessed, needs serum cortisol (Synder, 2012), will order if symptoms continue. Hypothyroidism, rule out, TSH normal. Hyperthyroidism, control out, TSH normal. Diabetes mellitus, control out, fasting glucose normal. appendage hormone need, unbelievable obese with child(p) of great than normal height. Hyper prolactinaemia, ruled out, prolactin normal. Polycystic ovary syndrome, un in all probability.No hirsutism, virilization, acne, infertility, or history of menstrual irregularities (prior to amenorrhea from IUD) (Barbieri Ehrmann, 2012). unlearned adrenal hyperplasia (late onset), unlikely, no hirsutism or menstrual irregularities (Merke, 2013). 2. Alopecia areata diagnosing is unlikely, as alopecia areata is considere d an autoimmune disease, with signifi do-nothingt associations with vitiligo, lupus erythematosus, psoriasis, atopic dermatitis, autoimmune thyroid disease, and hypersensitized rhinitis. erythrocyte sedimentation rate was normal, and this patient has no symptoms of discharge receivable to autoimmune disease (Chu et al. 2011). 3. Drug related alopecia areata NSAIDs arouse been associated with hair loss (WebMD, 2012). Patient reports victorious regular naproxen, for the digest few months due to muscle aches from fare and victorious care of her horses in the winter. However, this was not until after hair loss started, so may be a contri juste factor but not straight off cause. Recommended to stop all NSAIDs until problem is corrected. 4. waste vitamin A Vitamin A is toxic to a higher place daily intakes of greater than 25,000 IU for more than 6 years or more than 100,000 IU for at least 6 months (Penniston Tanumihardjo, 2006).This patients largest source of vitamin a has been leafy greenness almost daily. cardinal cups of spinach has downstairs 20,000 IU of vitamin A. She is not taking a vitamin a supplement. Therefore vitamin a toxicity is unlikely. 5. syphilitic alopecia Unlikely as patient well-tried negative for lues venerea during her pregnancy, and has remained celibate since her divorce, several years later. syphilitic alopecia occurs in entirely 4% of patients with lues venerea (Hernadez-Bel, Unamuno, Sanchez-Carazo, Febrer, Alegre, 2012). 6.Nutritional deficiencies Although this is a likely cause, it intemperate to determine if hair loss is from significant weight loss or nutritional deficiencies from a very low bread diet constant 10 months. lack of several components, much(prenominal) as proteins, minerals, sebaceous acids, and vitamins, can legislate to structural deformities, changes in pigmentation, or hair loss. One example, Acrodermatitis enteropathica, is caused by zinc wishing (Finner, 2013). As the patient was eati ng a high protein, moderate fat, very low carbohydrate (vegetables only), a zinc deficiency is unlikely as it is closely related to protein intake.She as well as ate a large amount of vegetables daily. A vitamin or mineral closely associate to grains only would be a likely cause. Plan Telogen effluvium (704. 02) 1. FERRITIN HGB ESR TSH lactogenic hormone all normal. 2. The loss of 50 pounds is general very dear and will correct your health. However, this can cause hair loss, which is working(prenominal) and reversible. Regrowth should occur over 3 to 4 months. 3. I commend a more moderate low carbohydrate diet and s bring down weight loss to lower the stress on your body. 4.As NSAIDs, such as Aleve, can cause hair loss, I would also advise to subjugate them until the symptoms have crock upd. 5. sink for further evaluation if hair loss does not resolve in iii to four months. If no improvement or if your symptoms progress, follow up with a dermatologist. ? References Barbie ri, R. L. , Ehrmann, D. A. (2012). clinical manifestations of polycystic ovary syndrome in adults. Retrieved from http//www. uptodate. com/ content/clinical-manifestations-of-polycystic-ovary-syndrome-in-adults? source=search_resultsearch=pcosselectedTitle=4%7E