HYPOTHYROIDISM SOAP NOTE

Hypothyroidism SOAP NOTE

Patient Initials: Age:  Gender: 

SUBJECTIVE DATA: 

Chief Complaint (CC): “ ”. 

History of Present Illness (HPI): 

Medications: 

Allergies: 

Past Medical History (PMH): 

Current medication: 

Past Surgical History (PSH): 

Family History: 

Personal/Social History: 

Immunization: up to date. 

Lifestyle: 

Review of Systems: 

General: 

HEENT: 

Neck: 

Breasts: 

Respiratory: 

Cardiovascular/Peripheral Vascular: 

Gastrointestinal: 

Genitourinary: 

Musculoskeletal: 

Psychiatric: 

Neurological 

Skin: 

Hematologic: 

Endocrine: 

OBJECTIVE DATA: 

Physical Exam:

Vital signs: Temperature: ; BP:  mmHg; HR: bpm; RR:  /min; Oxygen Saturation: %; Pain: (0-10 scale), Weight lb; Height; BMI 

General:. 

HEENT: 

Neck: 

Chest

Lungs: 

Heart: 

Peripheral Vascular: 

Genital/Rectal: 

Musculoskeletal: 

Neurological: 

Skin: 

ASSESSMENT: 

Differential Diagnosis

1. Hyperthyroidism. 

2. 

3. 

From both the subjective and objective data, it is clear that the main diagnosis is 

PLAN: 

Treatment Plan: (please prescription with dose)

Non-pharmacological approaches

For the follow-up, the patient should get back to the hospital after 

References: 2 or 3 with APA format

  

Soap Note 2 Chronic Conditions (15 Points)

Pick any Chronic Disease from Weeks 6-10

Follow the MRU Soap Note Rubric as a guide:

Use APA format and must include minimum of 2 Scholarly Citations.

Soap notes will be uploaded to Moodle and put through TURN-It-In (anti-Plagiarism program)

Turn it in Score must be less than 50% or will not be accepted for credit, must be your own work and in your own words. You can resubmit, Final submission will be accepted if less than 50%. Copy paste from websites or textbooks will not be accepted or tolerated. Please see College Handbook with reference to Academic Misconduct Statement.

Please use the sample t