SOAP Note for Naturopathy

Chief Complaints

Fatigue, abdominal bloating, and bilateral wrist stiffness.

Subjective

Elena Rostova, 42-year-old female, presents for naturopathic evaluation of chronic fatigue, digestive disturbances, and joint stiffness impacting daily occupational tasks.

• Chronic fatigue, postprandial bloating, and bilateral wrist arthralgia.

Patient seeks integrative management for low energy, persistent GI bloating, and morning wrist stiffness, and requests a comprehensive hormone and thyroid panel review.

• Fatigue onset 6 months ago, constant, rated 6/10 in severity; bloating occurs 30 min postprandial, daily, diffuse abdominal tightness; wrist stiffness present for 3 months, worse in the morning (lasting 45 min), dull ache rated 4/10.

• Bloating aggravated by dairy and wheat, mildly relieved by peppermint tea and topical heat; wrist stiffness aggravated by repetitive typing, relieved by warm water immersion and gentle stretching; fatigue transiently improved with mid-day rest.

• Fatigue and bloating have progressively worsened over the past 2 months; wrist stiffness remains stable.

• Experienced mild postpartum fatigue 8 years ago, managed with iron supplementation with full resolution; no prior history of chronic GI or joint symptoms.

• Fatigue limits afternoon productivity as a graphic designer; wrist stiffness impairs fine motor control during digital illustration and prolonged computer use.

• Associated with mild diffuse hair thinning, dry skin, and occasional constipation (bowel movements every 2–3 days).

Pertinent Information from Side Conversation

• Expresses high occupational stress due to upcoming freelance deadlines and frustration regarding the lack of definitive answers from prior conventional evaluations.

Past Medical History

Active Allergies

• Penicillin (maculopapular rash)
• Sulfonamide antibiotics (hives)
• Latex (contact dermatitis)

Active Medications

• levothyroxine (Synthroid®) 50 mcg PO daily
• cetirizine (Zyrtec®) 10 mg PO daily PRN
• sumatriptan (Imitrex®) 50 mg PO PRN

Active Supplements

• cholecalciferol (Vitamin D3) 2,000 IU PO daily
• magnesium glycinate 200 mg PO QHS
• probiotic blend (Lactobacillus/Bifidobacterium) 25 billion CFU PO daily

Active Diagnoses

• Primary hypothyroidism
• Irritable bowel syndrome with constipation (IBS-C)
• Bilateral carpal tunnel syndrome, mild

Procedures, Surgeries and Hospitalization

• Laparoscopic appendectomy (12/05/2014)
• Low transverse cesarean section (18/09/2018)
• Wisdom teeth extraction (04/06/2005)

Health Care Management

• Most recent wellness examination: 14/11/2025
• Most recent Pap test: 14/11/2025, NILM, HPV negative
• Colonoscopy: Deferred (average risk, scheduled at age 45 in 2029)
• Mammography: 22/11/2025, BI-RADS 1 (negative)
• Skin-cancer screening: 10/08/2025, benign nevi
• HCV reactivity status: Non-reactive (14/11/2025)

Family History

• Mother: Alive, age 68, history of Hashimoto's thyroiditis and osteoarthritis
• Father: Alive, age 71, history of essential hypertension and T2DM
• Maternal Aunt: History of celiac disease

Social History

• Occupation: Full-time freelance graphic designer (sedentary, 8–10 hours/day at computer)
• Tobacco/Alcohol: Never smoker; consumes 1–2 glasses of red wine per week
• Diet/Exercise: Omnivorous diet, high intake of refined carbohydrates when stressed; walks dog 20 min daily

Review of Systems

• Constitutional: Reports persistent fatigue and cold intolerance; no fever or unintentional weight loss
• Gastrointestinal: Reports postprandial bloating, flatulence, and constipation; no hematochezia or dysphagia
• Musculoskeletal: Reports bilateral morning wrist stiffness and mild arthralgia; no joint swelling or erythema
• Integumentary: Reports dry skin and mild diffuse alopecia; no rashes or lesions
• Neurological: Reports occasional mild paresthesia in digits 1–3 bilaterally after prolonged typing; no weakness or dizziness
• Denies chest pain, palpitations, shortness of breath, dysuria, hematuria, depression, or suicidal ideation

Objective

Physical Examination

• Constitutional: Calm and cooperative, with no acute distress; development and nutritional status appear appropriate. Vitals: BP 116/74 mmHg, HR 64 bpm, Temp 36.4 °C, Wt 64.5 kg.
• Neurological — Mental Status: Awake, alert, and oriented to person, place, and time. Phalen's test mildly positive bilaterally at 45 seconds; Tinel's sign negative at the wrists.
• Psychiatric: Recent and remote recall are preserved.
• General behavior, consciousness, thought content, and emotional presentation are appropriate and without notable abnormality.

Labs:

• TSH: 3.85 mIU/L (suboptimal for symptom control), Free T3: 2.3 pg/mL (low-normal), Free T4: 1.0 ng/dL
• Anti-TPO antibodies: 142 IU/mL (elevated)
• Serum Ferritin: 18 ng/mL (low), 25-OH Vitamin D: 32 ng/mL

Imaging:

• Thyroid Ultrasound (15/01/2026): Mildly heterogeneous echotexture consistent with chronic lymphocytic thyroiditis; no discrete nodules.
• Bilateral Wrist X-ray (20/01/2026): Unremarkable; joint spaces preserved, no erosions or osteophytes.
• Abdominal X-ray (20/01/2026): Moderate stool burden in the ascending and transverse colon; no obstruction.

Previous Pertinent Labs/specialized testing:

• Comprehensive Metabolic Panel (14/11/2025): Fasting glucose 92 mg/dL, AST 18 U/L, ALT 16 U/L, eGFR > 90 mL/min
• CBC with Differential (14/11/2025): WBC 5.4 x 10^3/uL, Hgb 12.6 g/dL, MCV 84 fL, Plt 245 x 10^3/uL
• Tissue Transglutaminase (tTG) IgA (14/11/2025): < 2 U/mL (negative), Total IgA: 185 mg/dL

Assessment

Evaluation and Management Services

Non-face-to-face time recorded for the date of the encounter

• 25 min spent updating the HPI and vitals, reviewing pertinent physical-examination findings, laboratory data, medications and supplements, managing and prescribing medications, discussing recommended follow-up, and documenting the visit.

Clinical Discussion

1. Chronic Fatigue and Suboptimal Thyroid Function

• Hashimoto's thyroiditis with non-anemic iron deficiency
• Chronic fatigue syndrome, HPA-axis dysfunction
• Salivary 4-point cortisol panel
• Transition thyroid replacement to desiccated thyroid extract or adjust levothyroxine, and initiate targeted selenium and iron supplementation; selenium supplementation is supported to reduce anti-TPO antibodies and improve mood in autoimmune thyroiditis (Wichman et al., 2016), while correcting ferritin levels < 50 ng/mL improves unexplained fatigue in premenopausal women (Vaucher et al., 2012)
• Endocrinology consultation if thyroid titers remain refractory

2. Postprandial Bloating and Constipation

• Irritable bowel syndrome with constipation (IBS-C)
• Small intestinal bacterial overgrowth (SIBO), non-celiac gluten sensitivity
• 3-hour lactulose breath test for hydrogen and methane
• Initiate a 4-week trial of a gluten- and dairy-free elimination diet alongside partially hydrolyzed guar gum (PHGG) and magnesium citrate; PHGG has been demonstrated to normalize bowel habits and reduce bloating in IBS-C without excess gas production (Niv et al., 2016)
• Gastroenterology referral if alarm symptoms develop

3. Bilateral Wrist Stiffness and Paresthesia

• Mild bilateral carpal tunnel syndrome and hypothyroidism-associated arthralgia
• Early seronegative rheumatoid arthritis, repetitive strain injury
• ESR, CRP, Rheumatoid Factor (RF), and Anti-CCP antibodies
• Initiate curcumin phytosome supplementation and ergonomic workstation modifications; bioavailable curcumin formulations demonstrate significant analgesic and anti-inflammatory effects in peripheral musculoskeletal disorders (Daily et al., 2016)
• Occupational therapy referral for ergonomic assessment, custom nocturnal wrist splinting, and tendon gliding exercises

Diagnoses

• Hashimoto's thyroiditis (E06.3)
• Iron deficiency without anemia (E61.1)
• Irritable bowel syndrome with constipation (K58.1)
• Bilateral carpal tunnel syndrome (G56.03)

Here is the plan, Elena! It was a pleasure seeing you today!

Nutrition/Lifestyle

• Begin a 4-week elimination of gluten and cow's dairy to help calm gut inflammation and reduce bloating; Dr. Shah will help you reintroduce foods systematically at your next visit.
• Increase daily water intake to at least 2 L per day, focusing on warm water or herbal tea between meals to support bowel motility.
• Take a 5-minute break from your computer every hour to perform gentle wrist stretches, and wear neutral wrist braces at night to take pressure off your nerves.

Supplements

Continue

• cholecalciferol (Vitamin D3) 2,000 IU PO daily
• probiotic blend (Lactobacillus/Bifidobacterium) 25 billion CFU PO daily

Discontinue

• magnesium glycinate 200 mg PO QHS

Add

• iron bisglycinate 25 mg PO every other day on an empty stomach with 250 mg Vitamin C
• selenomethionine 200 mcg PO daily with food
• magnesium citrate 300 mg PO QHS mixed in water for bowel motility
• curcumin phytosome (Meriva®) 500 mg PO BID with meals
• partially hydrolyzed guar gum (Sunfiber®) 5 g PO daily mixed in water

Prescriptions

Continue

• cetirizine (Zyrtec®) 10 mg PO daily PRN
• sumatriptan (Imitrex®) 50 mg PO PRN

Discontinue

• levothyroxine (Synthroid®) 50 mcg PO daily

Add

• levothyroxine (Synthroid®) 75 mcg PO daily (take on an empty stomach 60 minutes before breakfast and 4 hours apart from iron or magnesium supplements)

Follow-up Labs

• Please return for repeat laboratory testing (TSH, Free T3, Free T4, Ferritin, ESR, CRP, RF, Anti-CCP) and complete your at-home SIBO breath test in 6 weeks, and schedule a follow-up visit with Dr. Shah two weeks afterward (in 8 weeks total) to review the results.

Other

• Dr. Shah has placed a referral for you to see an Occupational Therapist for a formal workstation ergonomic evaluation and hand therapy. Seek prompt medical attention if you develop severe abdominal pain, blood in your stool, or sudden weakness or loss of sensation in your hands.