Focused SOAP Note for a Patient with Proptosis and Fatigue

Focused SOAP Note for a Patient with Proptosis and Fatigue
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Focused SOAP Note for a Patient with Proptosis and Fatigue
Patient Information
Initials: K.M.
Age: 44
Sex: Female
Race: Not specified
S.
CC: Proptosis and fatigue.
HPI
Kali, a 44-year-old female, presents with a chief complaint of proptosis and fatigue. She reports that her eyes have been bulging and protruding more prominently recently, although the exact duration is unknown. Kali describes a sensation of pressure around her eyes and temples. Additionally, she complains of feeling consistently tired and needing more energy, despite getting sufficient rest. These symptoms have impacted her daily activities, including work and personal life. Kali denies experiencing any associated symptoms, such as headaches, nausea, vomiting, or vision changes.
Timing
Proptosis. Kali reports experiencing proptosis after being on the computer all day at work. This experience indicates a temporal relationship between her work activities and the symptom onset. The duration of proptosis after exposure to prolonged computer use should be further explored during the examination.
Exacerbating/Relieving Factors
Proptosis. Kali mentions that light bothers her eyes, suggesting bright light worsens her symptoms. Additionally, she states that taking Aleve (a nonsteroidal anti-inflammatory drug) makes the symptoms tolerable but does not entirely alleviate them. These factors provide insight into the triggers and potential treatment options for managing her proptosis.
Severity
Proptosis. On a pain scale of 0 to 10, Kali rates the severity of her proptosis as 7/10. This rating suggests a significant level of discomfort and distress caused by the bulging and protrusion of her eyes.
Current Medications: None reported.
Allergies: No known allergies.
PMHx: No significant past medical history was provided.
Soc Hx: Kali works in an office with prolonged computer use. She is married and has two children. She denies tobacco or alcohol use. No other pertinent information was reported.
Fam Hx: No information provided.
ROS: General: Kali is fatigued and denies weight loss, fever, chills, and weakness.
Eyes: Reports proptosis and feeling pressure around the eyes.
EENT: Denies visual changes, headache, or other symptoms.
Cardiovascular: No chest pain, palpitations, or edema.
Respiratory: Denies shortness of breath, cough, or sputum.
Gastrointestinal: No gastrointestinal symptoms were reported.
Genitourinary: No urinary complaints or changes in the menstrual cycle.
Neurological: No headaches, dizziness, or changes in sensation.
Musculoskeletal: No muscle or joint pain/stiffness.
Hematologic: No history of anemia or bleeding.
Psychiatric: No history of depression or anxiety.
Endocrine: No reports of sweating, cold or heat intolerance, polyuria, or polydipsia.
Allergies: No history of asthma, hives, eczema, or rhinitis.
O
Physical Exam
General: The patient appears overweight.
Neck: Swollen appearance.
Eyes: Proptosis noted.
Cardiovascular, respiratory, gastrointestinal, musculoskeletal, and other systems were not examined due to a lack of rele...