Unit 5 Ihuman Maria Ash

CC: Fatigue and weight gain

Questions

Onset: when did the fatigue start?

Location:

Duration: does this last all day or even after a good night of rest?

Characteristics: Aggravating/Relieving: does anything make the fatigue better or worse?

Treatment: Have you tried anything to help?

When did you first notice the weight gain? How much weight have you gained?

Have you tried anything to lose weight?

Have you always felt cold when other were warm?

Did you just start to notice decreased energy?

Do you have pain or swelling in your neck? Radiation to the neck?

Previous endocrine problems?

Dietary questions (?)

Classic early symptoms include fatigue, dry skin, slight weight gain, cold intolerance,

constipation, and heavy menses

Myalgia, muscle cramps, headaches, and weakness may also be present

Later symptoms: very dry skin, coarse hair, loss of lateral eyebrows, alopecia, hoarseness, weight

gain, slight impairment in mental ability, depression, decreased libido, and hypersomnia

Women require a full menstrual history including date of most recent period, characteristics, and

duration

More specific to Hashimoto’s-painless thyroid enlargement, neck pain, sore throat, a feeling of

fullness in the throat, low grade fever, and exhaustion

Mild diastolic hypertension

Family history- ask about thyroid problems

History of thyroid surgery or radiation in your neck to treat cancer

Are you currently on any medication (amiodarone, lithium, interferon alpha, iodine,interleukin-2

or prior chemotherapy can cause these issues)

SOAP NoteMariah AshMariah Ash - 41 year old woman with 65kg complaining of weight gain and

fatigue.

1)How can I help you today?- fatigue, it’s getting harder and harder to get through a normalwork today

2)Do you have any other symptoms or concerns we should discus? – Gaining weight, but I swear I am

watching what I eat. Bowel habits, I seem to have some constipation

Fatigue-onset,

When did your fatigue/tiredness start?

Do you become more weak or tired with exertion? – Yes, I got tired doing household tasks like

gardening. I feel some days I need to take an afternoon nap. I try to keep going through anyway

How severe is your fatigue/tiredness?- I guess I’m mostly funcining, but It’s concerning enough that I

came in to find out why and ge to the bottom

Have you had fatigue/tiredness problems like this before?

Has there been any change in your fatigue/tiredness over time?Not much, maybe a bit worse lately

Does your fatigue/tiredness improve after a good night’s rest? – Some, but not back to normal

Is your fatigue unrelated to physical effort?- I don’t have my normal energy when I wake up, but Ifeel

really tired at the end of the day. This is not normal for me. I usually feel energized after teaching classes.

I’m the oldest fitness trainer at the gym.