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