SOAP Note
Prepared by: Beverly D. Fay, Vibrant Vision Studios
This SOAP note prepared by Beverly D. Fay of Vibrant Vision Studios is written with utmost precision, providing detailed information on diagnosis, treatment plans and session interactions with our patient, Emma Hernandez.
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Subjective
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Patient: Emma Hernandez, Female, Age: 29
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Patient mentions recurring headaches, constant fatigue and mild dizziness
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Feels moderate discomfort during intense physical activity
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Patient denies any recent trauma or injuries
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No known drug allergies
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Objective
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Height: 5'4", Weight: 135 lbs.
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Patient's vital signs within normal range
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Physical exam found no significant abnormalities
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No signs of distress, normal heart and lung sounds
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Laboratory tests ordered
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Assessment
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Patient's symptoms may indicate chronic fatigue syndrome (CFS)
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However, further diagnostic tests are needed to make definite conclusions
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Depression and anxiety ruled out based on Patient Health Questionnaire (PHQ-9) score
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Lab results awaited to rule out any underlying metabolic or infectious disease
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Plan
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Patient to follow up after laboratory results are available
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Advise patient to maintain good sleep hygiene and balanced diet
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Patient referred to nutritionist and physiotherapist to aid in managing energy levels and handling fatigue
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Suggest regular 3-month review for monitoring fatigue levels
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Date of the patient evaluation: August 16, 2053
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