Annotated Soap Note Hair Loss
Chief complaint: hair loss that started several months ago.
History of Present Illness
This 45 year old female presents with:
1. Hair loss The patient presents with hair loss that began 5 months ago. The problem is mild to moderate and has worsened. The initial location of hair loss was the diffuse scalp and temporal region that occurred gradually. Symptoms are associated with very low carbohydrate dieting and new medication within 3 - 6 months (Aleve). Symptoms are not associated with hair pulling, increased psychological stress, fever, recent illness, recent surgery or scalp rash. Relevant history positive for family history of hair thinning on both sides. Relevant history negative for anemia, hyperthyroidism, hypothyroidism, rheumatoid arthritis, vitiligo or ulcerative colitis. The patient is not currently pregnant. Associated symptoms include intentional weight loss of 50 lbs over 10 months. Pertinent negatives include anxiety, depression, dry scalp, fever, heat intolerance, itchy scalp, rash, scalp kerion, scalp tenderness or skin sores. Noticed hair thinning for about 5 months. No bald spots, lesions on scalp or skin. Estimates she has lost 25% of hair thickness. Chronic Problems
Past Medical/Surgical History
1996 (R) Shoulder arthroscopy
Obstetric History
G1P1. Not pregnant.
Family History
Disease Detail Family Member Age
Cardiomyopathy Father 67 (cause of death)
Cancer -lung Mother 59 (cause of death)
Hypothyroid Mother
Social History
Employment: Property Management, no exposure to chemicals.
Marital Status / Family: Currently single, previously divorced once, not in relationship since divorce. Has an 11-year-old daughter.
Tobacco: Never smoked.
Alcohol: Occasional beer.
Caffeine: coffee- 3 cups a day.
Lifestyle: Moderate activity level. Exercises 3-4 days per week and takes care of horses daily.
Medications (Active)
Medication Name
Mirena IUD, placed in 2012.
Aleve as needed, taking
History of Present Illness
This 45 year old female presents with:
1. Hair loss The patient presents with hair loss that began 5 months ago. The problem is mild to moderate and has worsened. The initial location of hair loss was the diffuse scalp and temporal region that occurred gradually. Symptoms are associated with very low carbohydrate dieting and new medication within 3 - 6 months (Aleve). Symptoms are not associated with hair pulling, increased psychological stress, fever, recent illness, recent surgery or scalp rash. Relevant history positive for family history of hair thinning on both sides. Relevant history negative for anemia, hyperthyroidism, hypothyroidism, rheumatoid arthritis, vitiligo or ulcerative colitis. The patient is not currently pregnant. Associated symptoms include intentional weight loss of 50 lbs over 10 months. Pertinent negatives include anxiety, depression, dry scalp, fever, heat intolerance, itchy scalp, rash, scalp kerion, scalp tenderness or skin sores. Noticed hair thinning for about 5 months. No bald spots, lesions on scalp or skin. Estimates she has lost 25% of hair thickness. Chronic Problems
Past Medical/Surgical History
1996 (R) Shoulder arthroscopy
Obstetric History
G1P1. Not pregnant.
Family History
Disease Detail Family Member Age
Cardiomyopathy Father 67 (cause of death)
Cancer -lung Mother 59 (cause of death)
Hypothyroid Mother
Social History
Employment: Property Management, no exposure to chemicals.
Marital Status / Family: Currently single, previously divorced once, not in relationship since divorce. Has an 11-year-old daughter.
Tobacco: Never smoked.
Alcohol: Occasional beer.
Caffeine: coffee- 3 cups a day.
Lifestyle: Moderate activity level. Exercises 3-4 days per week and takes care of horses daily.
Medications (Active)
Medication Name
Mirena IUD, placed in 2012.
Aleve as needed, taking
References: Finner, A. M. (2013). Nutrition and hair: deficiencies and supplements. Dermatology Clinics, 31(1), 167-172. http://dx.doi.org/10.1016/j.det.2012.08.015 Goldstein, B Shapiro, J., Otberg, N., & Hordinsky, M. (2013). Evaluation and diagnosis of hair loss. Retrieved from http://www.uptodate.com/contents/evaluation-and-diagnosis-of-hair-loss?source=search_result&search=hair+loss&selectedTitle=1%7E150#H1871427 Synder, P WebMD. (2012). Drug-induced hair loss. Retrieved from http://www.webmd.com/skin-problems-and-treatments/hair-loss/drug-induced-hair-loss