SOAP Note for Functional Medicine Template

Subjective Notes:  
Date: 2023-10-15  
Patient consulting reason: Persistent fatigue and gastrointestinal concerns  
Detailed patient history including presenting complaints, past medical history, current medications, and relevant symptoms: The patient, a 45-year-old female, reports ongoing fatigue and abdominal bloating. She has a medical history of hypothyroidism and irritable bowel syndrome (IBS). Her current medication regimen includes Levothyroxine 75 mcg taken orally once daily.  
Current medications:  
- Levothyroxine 75 mcg orally once daily  
Vitals:  
- Weight: 150 lbs  
- Height: 5'6"  
- BMI: 24.2  
Objective Notes:  
General physical examination findings: The patient appears fatigued but is not in acute distress. Her skin is warm and dry.  
Cardiovascular examination findings: Heart rate is regular, with no murmurs detected.  
Respiratory examination findings: Lungs are clear to auscultation bilaterally.  
Neurological examination findings: Cranial nerves II-XII are intact, and reflexes are normal.  
Notable Labs:  
Date of labs: 2023-10-10  
- TSH: 2.5 mIU/L  
- Free T4: 1.1 ng/dL  
- Vitamin D: 20 ng/mL (low)  
Assessment Section:  
Notes -  
- Hypothyroidism  
- Irritable Bowel Syndrome (IBS)  
- Vitamin D deficiency  
Practitioner Recommendations:  
For each condition:  
Condition name: Hypothyroidism  
Medication/Treatment name: Levothyroxine  
Dose: Continue 75 mcg orally once daily  
Side Effects/Expectations: Monitor for symptoms of hyperthyroidism  
Patient Decision: Agrees to continue current dosage  
Recheck Labs: TSH and Free T4 in 6 weeks  
Condition name: IBS  
Medication/Treatment name: Probiotic  
Dose: One capsule daily  
Side Effects/Expectations: May improve bloating and digestive health  
Patient Decision: Agrees to start probiotic  
Recheck Labs: None  
Condition name: Vitamin D deficiency  
Medication/Treatment name: Vitamin D3 supplement  
Dose: 2000 IU daily  
Side Effects/Expectations: Improve energy levels and bone health  
Patient Decision: Agrees to start supplementation  
Recheck Labs: Vitamin D level in 3 months  
Lifestyle:  
Diet recommendations: Increase fiber intake, reduce processed foods  
Exercise recommendations: 30 minutes of moderate exercise 5 times a week  
Stress management recommendations: Practice mindfulness meditation daily  
Patient Decision:  
Summary of patient's decisions regarding treatments and medications: The patient agrees to continue Levothyroxine, start a probiotic, and begin Vitamin D supplementation. She is committed to dietary changes and stress management practices.  
Follow-up:  
Follow-up instructions for various aspects of care: Return visit in 6 weeks for thyroid function tests  
Emergency instructions: Contact the clinic if experiencing symptoms of hyperthyroidism or severe abdominal pain.