Annotated Soap Note Hair Loss

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 Father67 (cause of death) Cancer -lungMother59 (cause of death) HypothyroidMother 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 several times a week over winter. Allergies: NKANo Known Drug Allergies Review of Systems Constitutional: Positive for: Weight loss. Has been following a very low carb diet and has lost 50 lbs. since July. No protein, nonstarchy vegetable or calorie restriction. Negative: fever and night sweats. Respiratory: Negative: cough, dyspnea. Cardiovascular: Negative: chest pain and irregular heartbeat/palpitations. Gastrointestinal: Negative: abdominal pain, constipation and diarrhea. Genitourinary: The patient is pre-menopausal. No menses with IUD. Negative: dysuria. Metabolic/Endocrine: Positive for hair loss, see HPI. Weight loss from diet and lifestyle changes. Negative: heat or cold intolerance. Neuro/Psychiatric: Negative: anxiety and depression. Negative: extremity weakness, headache and numbness or weakness in extremities. Dermatologic: No hirsutism or signs of virilization, nail changes, rash, or skin sores. Scalp without pruritus, burning, or lesions. No new hair products. Shampoos daily. No chemical hair treatments. No hair loss on other parts of body. Hair lost has roots, no hair breakage. Does not put hair into braids or ponytails on regular basis. See Chief Complaint and HPI. Musculoskeletal: Negative: joint pain and joint swelling. Hematology: Negative: easy bleeding, bruising or history of anemia. Vital Signs. Height: 5’8† Weight: 237 BMI: 36 Blood Pressure: 130/75 Pulse: 80 Physical Exam Constitutional: Well developed, no distress. Eyes: PERRLA, no injection, bilaterally. Neck / Thyroid: Symmetric, trachea midline and mobile. No thyromegaly or thyroid nodules. Lymphatic: No cervical or supraclavicular adenopathy. Respiratory: Chest symmetric. Lungs clear to auscultation. Respiratory effort is normal. Cardiovascular: Regular rate and rhythm with normal S1, S2. No murmur or rub. Abdomen: Nontender. No masses or organomegaly, exam limited by obesity. No bruits. Integumentary: No skin lesions present. Nails appear normal. No scalp erythema, scales, papules, pustules, erosions, or excoriations. Hair loss most noticeable in temporal region, equal bilaterally. Extremities: No edema is present. Psychiatric: Oriented to time, place, person, and situation. Has appropriate mood and affect. Assessment: Telogen effluvium (704. 02) Hair loss is classified into 3 classifications, cicatricial alopecia (inflammatory), nonscarring alopecia and inherited and acquired structural hair disorders. In evaluating hair loss it is important to assess duration and rate, location and pattern, extent of loss, associated symptoms, hair care practices, and differentiation of hair shedding from breakage. Medical and family history, diet, and medications need to be assessed (Shapiro, Otberg, Hordinsky, 2013). Telogen effluvium is diffuse hair loss that is reversible caused by a significant stressor such as significant weight loss, pregnancy, major illness or surgery (Goldstein Goldstein, 2012). As the patient has lost 50 pound in 10 months, this is the most likely cause of her diffuse hair loss. She will stop her very low carbohydrate diet for a more moderate, varied diet. If the hair loss continues she will need further evaluation. Differential diagnosis 1. Endocrine related hair loss: Hair loss may be caused by several endocrine disorders, presentation is typically with non-scarring alopecia that is diffuse (Olszewska, Warszawik, Rakowska, Slowinska, Rudnicka, 2011). †¢Hypopituitarism, not assessed, needs serum cortisol (Synder, 2012), will order if symptoms continue. †¢Hypothyroidism, ruled out, TSH normal. †¢Hyperthyroidism, ruled out, TSH normal. †¢Diabetes mellitus, ruled out, fasting glucose normal. †¢Growth hormone deficiency, unlikely obese adult of greater than normal height. †¢Hyperprolactinaemia, ruled out, prolactin normal. †¢Polycystic ovary syndrome, unlikely. No hirsutism, virilization, acne, infertility, or history of menstrual irregularities (prior to amenorrhea from IUD) (Barbieri Ehrmann, 2012). †¢Congenital adrenal hyperplasia (late onset), unlikely, no hirsutism or menstrual irregularities (Merke, 2013). 2. Alopecia areata : Diagnosis is unlikely, as alopecia areata is considered an autoimmune disease, with significant associations with vitiligo, lupus erythematosus, psoriasis, atopic dermatitis, autoimmune thyroid disease, and allergic rhinitis. ESR was normal, and this patient has no symptoms of inflammation due to autoimmune disease (Chu et al. 2011). 3. Drug related alopecia areata : NSAIDs have been associated with hair loss (WebMD, 2012). Patient reports taking regular naproxen, for the last few months due to muscle aches from exercise and taking care of her horses in the winter. However, this was not until after hair loss started, so may be a contributing factor but not direct cause. Recommended to stop all NSAIDs until problem is corrected. 4. Excess vitamin A: Vitamin A is toxic above daily intakes of greater than 25,000 IU for more than 6 years or more than 100,000 IU for at least 6 months (Penniston Tanumihardjo, 2006). This patient’s largest source of vitamin a has been leafy greens almost daily. Two cups of spinach has under 20,000 IU of vitamin A. She is not taking a vitamin a supplement. Therefore vitamin a toxicity is unlikely. 5. Syphilitic alopecia: Unlikely as patient tested negative for syphilis during her pregnancy, and has remained celibate since her divorce, several years later. Syphilitic alopecia occurs in only 4% of patients with syphilis (Hernadez-Bel, Unamuno, Sanchez-Carazo, Febrer, Alegre, 2012). 6. Nutritional deficiencies: Although this is a likely cause, it difficult to determine if hair loss is from significant weight loss or nutritional deficiencies from a very low carbohydrate diet lasting 10 months. Deprivation of several components, such as proteins, minerals, fatty acids, and vitamins, can lead to structural deformities, changes in pigmentation, or hair loss. One example, Acrodermatitis enteropathica, is caused by zinc deficiency (Finner, 2013). As the patient was eating a high protein, moderate fat, very low carbohydrate (vegetables only), a zinc deficiency is unlikely as it is closely related to protein intake. She also ate a large amount of vegetables daily. A vitamin or mineral closely linked to grains only would be a likely cause. Plan Telogen effluvium (704. 02) 1. FERRITIN HGB ESR TSH PROLACTIN all normal. 2. The loss of 50 pounds is overall very beneficial and will improve your health. However, this can cause hair loss, which is temporary and reversible. Regrowth should occur over 3 to 4 months. 3. I recommend a more moderate low carbohydrate diet and slower weight loss to lower the stress on your body. 4. As NSAIDs, such as Aleve, can cause hair loss, I would also advise to avoid them until the symptoms have resolved. 5. Return for further evaluation if hair loss does not resolve in three to four months. If no improvement or if your symptoms progress, follow up with a dermatologist. ? References Barbieri, R. L. , Ehrmann, D. A. (2012). Clinical manifestations of polycystic ovary syndrome in adults. Retrieved from http://www. uptodate. com/contents/clinical-manifestations-of-polycystic-ovary-syndrome-in-adults? source=search_resultsearch=pcosselectedTitle=4%7E

Effects of domestic violence on children Essay Example | Topics and Well Written Essays - 750 words

Effects of domestic violence on children - Essay Example Domestic violence creates a sense of deprivation in children because they need attention and care. When parents are busy fighting in the house, children cannot get the appropriate attention they need. The long term effects of domestic violence can be severe and may include drug abuse, alcohol addiction, and subservient behavior. In this essay we will focus on the perilous effects of domestic violence on children. Drug Abuse Children are immature when it comes to their understanding of the world around them. They have no idea about the dynamics of marital life therefore they do not understand the physical or verbal abuse they witness in their homes. The worst moment is when a child is attempting to understand why his or her parents are fighting. While connecting the dots in order to find the reason behind the chaos in home, the child ends up either believing that he or she is causing the problem or becomes frustrated and tries to look a doorway out form the situation. Parents expect t hat a teenager should understand the stress they face in their office life? A 13 year old is not equipped to handle such problems because his mind is still immature. Parents should understand this before fighting in front of children. A child has no option but to go outside, and stay outside for a long time when the environment of home is not friendly. In an attempt to escape from the troubles of home children start to hang outside and this is when they engage into bad activities like drug abuse. Children are also susceptible to peer pressure therefore are easy targets of drug abuse. Domestic violence also creates a need to grow inside children so that they can escape the situation in which they are in. And because they want to become adults quickly, they pretend to do what elders do. This is how children who experience domestic violence indulge in drug abuse. Alcohol Addiction Alcohol addiction is way through which teenagers try to forget the miseries of their life. The family life gives them so much trouble that they want to forget everything about the home. Alcohol seems to be the only alternative that is easily available and it also helps teenagers. Domestic abuse is known to affect the stability and well being of the children (Rossman, 36). Alcohol addiction is a way in which the well being of children is affected. Alcohol addiction is not a sudden outcome of domestic violence. Children are slowly and gradually detached from their family, and then they become addicted to alcohol. It can therefore be said that alcohol addiction is a long term consequence of domestic abuse. There comes a time in a child’s life when he or she hangs out with his or her friends outside of home. This is after 14 or 15 years of age, and this is the time when teenagers are most susceptible to alcohol addiction. Children who face domestic violence crave for attention and my want to fit in. This is why they are more susceptible to alcohol addiction. Subservient Behavior Chil dren who see or experience domestic violence become subservient. They are usually too weak to make a difference and this breeds helplessness. This helplessness is not unlearned throughout their life because a childhood is the time when personality is molding. Any significant incident in the childhood is therefore impacts the whole future life of a person. Submissive behavior is witnessed in children who face domestic violence (Goodman & Rosenberg). Domestic abuse also makes children dependent on others. Because they have never been control of

Interview report Essay Example | Topics and Well Written Essays - 1250 words

Interview report - Essay Example The interview was carried out in his small office, and the subject was asked ten questions to which he responded comprehensively. Interview responses The subject expressed his passion for teaching language especially to ESL students because as he put it, â€Å"teaching someone a new language is as good as creating a new life. â€Å"You see them change over time and you can’t help but be delighted†. When asked whether he uses computer software to teach English, his response was affirmative and he said that computer software makes a good part of his teaching. This was followed by a follow-up question. Have you always used computer software in the language vocabulary acquisition for ESL students? His response was: when I began teaching English to ESL students, there was no computer software to offer second language acquisition and teaching was mainly done using one to one communication with the students and also by the use of books. However, as computers became more popul ar, the use of computers to teach language became very popular too, and there have been numerous computer nuggets that were designed to help ESL students to learn English vocabulary very efficiently. This software can be classified into two classes, those designed to be used by ESL students who are learning on their own; and those designed to be used in conjunction with the teacher. This software started becoming available and popular in early 2000s and was not popular in the 90s (Peterson, 2009). I only started to use it later after I had been teaching English for a number of years to ESL students. Follow up question: do you see any positive difference between now that you are using the software and when you were not using software to teach ESL students? He responded to this follow up question by saying that there were positive and negative consequences of using computer application for language vocabulary acquisition. The use of computer applications by students and especially ESL students to learn new vocabulary is helpful because the computer applications that the students use make it easy for the students to access information in a more convenient way. However, this will depend on whether the student is conversant in the use of computer in general. If the student is not very savvy with regard to the use of computers, using these applications will not help very much in making the student learn vocabulary, but will only make it harder. The subject was indicating that computer packages can be used to increase the efficiency by the students to learn new vocabulary, but this can only happen if the students are computer savvy. He added that in most cases, ESL students are also not computer literate, and this causes a big challenge in getting them to use the computer application to learn new vocabulary. The next question was: why would computer software be useful in helping the students be able to acquire language acquisition? This question was asked in order fo r the subject to demonstrate why he thinks that the use of software can be useful in some cases to help the ESL students to learn new language vocabulary. His response was: â€Å"With the use of computers, it is much easier to browse through the information because computers work very fast. When a student is using a computer application to learn the meaning of a new word, he is able to browse the database and get a number of important aspects of a new