Free Family Medicine Soap Note

Prepared by: [Your Name]

I. Subjective

A. Chief Complaint

The patient reports feeling fatigued for the past 2 weeks, with a decrease in energy levels and difficulty concentrating.

B. History of Present Illness

The patient, a 38-year-old female, states that her fatigue has gradually worsened over the past two weeks. She mentions occasional headaches, no fever, and no recent changes in diet or exercise. Denies any significant stress at work or home. No history of recent travel or exposure to illness.

C. Past Medical History

• Hypertension, controlled with medication

• No history of diabetes, asthma, or major surgeries

D. Medications

• Lisinopril 10mg daily

• Multivitamin

E. Allergies

• No known drug allergies (NKDA)

F. Family History

• Mother: Hypertension, type 2 diabetes

• Father: Heart disease, deceased at 65

G. Social History

• Non-smoker

• Social drinker (1-2 glasses of wine per week)

• Works as a marketing manager from home

H. Review of Systems

• General: Reports fatigue and low energy

• Cardiovascular: No chest pain or palpitations

• Respiratory: No shortness of breath or cough

• Neurological: Occasional headaches, no dizziness or syncope

II. Objective

A. Vital Signs

B. Physical Examination

C. Laboratory Results

III. Assessment

The patient presents with fatigue that has gradually worsened over the past two weeks. There are no signs of acute illness or concerning neurological symptoms. The most likely differential diagnoses include:

• Primary Diagnosis: Fatigue likely related to stress or mild depression

• Secondary Diagnosis: Possible anemia or early hypothyroidism (though lab results are normal)

IV. Plan

A. Diagnostic Plan

• Continue monitoring vital signs and review lab results at follow-up

• Consider ordering iron studies or a sleep study if symptoms persist

B. Therapeutic Plan

• Recommend daily exercise (e.g., walking 30 minutes/day)

• Encourage good sleep hygiene and stress management techniques

C. Follow-up Plan

• Follow up in 2 weeks to reassess fatigue and discuss the results of any additional tests.

• Schedule a mental health assessment if fatigue persists without a clear cause.

D. Patient Education

• Advised the patient on the importance of regular exercise, sleep, and stress management

• Provided handouts on improving sleep hygiene and managing stress

E. Referrals

• None at this time, unless symptoms worsen or persist.

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