Make a SOAP note along with ROS and Physical exam for a patient that presents with the
following:
You will need to place the information in the appropriate sections and make your own ROS, and physical exam. Include 3 differential diagnosis, labs, plan of care, and education. 

 

40-year-old female presents to your office for a wellness exam. She complains of increased fatigue, not being andto lose weight. Has a history of IBS-D with episodes of constipation.Patient reports no fever, no night sweats, no significant weight loss, no exercise intolerance, and no chills.Complaints of increased fatigue despite getting plenty of rest. Concerned because she is not able to loseweight despite exercise and dietary changes. She reports no chest pain, no arm pain on exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, no known heart murmur, and no ankle swelling. She reports no cough, no wheezing, no shortness of breath, no coughing up blood, and no sleep apnea. She reports no abdominal pain, no nausea, no vomiting, no constipation, normal appetite, no diarrhea, not vomiting blood, no dyspepsia, and no GERD. She reports no incontinence, no difficulty urinating, no hematuria, and no increased frequency. She reports no muscle aches, no muscle weakness, no arthralgias/joint pain, no back pain, no swelling in the extremities, no neck pain, no difficulty walking, no cramps, no osteoporosis, and no fractures.
PMH-negative
FH-Mom with hypothyroidism
Dad-HTN
SH-non-smoker, no alcohol consumption
Medications-none
VS: HT-5'8 B/P-110/62 P-71 WT-167 BMI-25
Labs-
TSH 2.84, T4 1.2 TPA 211 All other labs were normal.