CHIEF COMPLAINT: Full physical and hair loss.
SUBJECTIVE: The patient presents today for evaluation and full physical. In general, she is feeling fine. She has been taking calcium and vitamin D since last year when it was noted that she was vitamin D deficient. She complains of some hair loss ever since she stopped the oral contraceptives back in March of this year. She states that she has not been stressed out. Her skin has not been any more dry than usual, and she wonders whether the hair loss is secondary to the discontinuance of the oral contraceptive.
PAST MEDICAL HISTORY: History of tobacco abuse, uterine fibroid, and vitamin D deficiency.
CURRENT MEDICATIONS: Calcium plus D 600/400 daily. No oral contraceptives since MM/DD/YYYY.
ALLERGIES: None.
FAMILY HISTORY: Unremarkable. No early coronary artery disease, breast, uterine, ovarian or colon cancer.
OBJECTIVE: The patient is a very pleasant lady, in no acute distress. Her blood pressure today is 118/64, heart rate 84. She is 5 feet 5 inches tall, weighs 112 pounds, temperature 97.8, and O2 saturation is 99%. HEENT: Normocephalic, atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular muscles are intact. Anicteric sclerae. Oropharynx is clear. Tongue is midline. Neck is supple. No lymphadenopathy or thyromegaly. Lungs: Clear bilaterally to auscultation. No wheezing, rales or rhonchi. Cardiac: Regular rate and rhythm. S1, S2 without murmurs, gallops or rubs. Abdomen: Soft, scaphoid, nontender. No hepatosplenomegaly, masses or bruits were appreciated. Skin is warm and dry without petechia or concerning lesions. We did not note significant alopecia.
ASSESSMENT AND PLAN:
1. Full physical exam in a healthy (XX)-year-old woman, up-to-date on her immunizations. We will schedule her for a mammogram.
2. Vitamin D deficiency: We will check a vitamin D level.
3. History of anemia with a history of uterine fibroid: We will recheck a CBC this year. Last year, she was borderline anemic.
4. Hair loss: Unclear etiology. We will check a TSH. We also discussed stress as a potential causative etiology; although, she states that she had not been very stressed out. We suppose presumably any hormonal changes could precipitate some hair loss. We will check her thyroid. We will see her again in 1 year or sooner if issues arise.
