Episodic/Focused SOAP Note Template Patient Information: 32 year old Female, African American. S.

Episodic/Focused SOAP Note Template Patient Information: 32 year old Female, African American. S.

CC: ‘My hair is falling out.” The patient stated that she has gained 30 pounds within a year yet

had suppressed appetite. She also stated that she feels cold all the time and has difficulty

sleeping. The patient pointed out that she still enjoys her hobbies and does not believe she is

depressive.

HPI: Location: general insomnia and feeling cold on the entire body

Onset: the last three weeks

Character: Patient appeared pleasant though she had dark circles under her eyes from the

insomniac episodes. Patient was also fatigued

Associated signs and symptoms: hypothermia and feelings of body weakness. Patient’s

hair is falling out; she observed chunks of hair on her hair brush

Timing: Often times the patient experiences malaise in the evenings. Patient reported that

she feels warm only after basking in the sun; she feels cold throughout the day and night.

Exacerbating/ relieving factors: Basking in the sun or sitting by the fireside at evening

times makes her feel warmer

Severity: No pain reported.

Current Medications: Patient takes valerian tea before retiring for bed

Allergies: Patient reports to be allergic to peanuts. She is also allergic to hay. Patient is allergic

to iodine. No intolerance to any medication was reported