DATE OF SERVICE: MM/DD/YYYY
REASON FOR VISIT: Hair loss.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female, who comes in today with the above concern. She reports that over the past 6 months, she has noticed some thinning of her hair. Specifically, she noticed that it comes out in clumps from the root. At first, the patient thought this was perhaps due to coloring her hair and had discussed this with her hair stylist. However, she notes that she has been using the same process for many years, and it was reported to her that typically chemical damage would result in breakage as opposed to hair coming off at the root.
The patient also notes that approximately 6 months ago, she began on lamotrigine, which was prescribed for control of her bipolar disease. She reports that this has been extremely helpful in terms of her mood. However, she had done some reading online and thought this might be contributing to her hair loss. Review indicates that alopecia is a very rarely reported side effect of this medication. However, the patient states that she would continue on this medication.
The patient also admits that she has been under a lot of stress over the past year and acknowledges that this may be playing a role. The patient denies any fatigue, headaches, dizziness, weakness, shortness of breath, chest pain, gastrointestinal upset, or muscle pain and notes that otherwise she has been feeling very well. She is a bit overdue for her routine studies. The patient states that she needs to schedule an appointment with her gynecologist and also would like to have her mammogram arranged.
CURRENT MEDICATIONS: Lamotrigine.
ALLERGIES: None known.
PHYSICAL EXAMINATION:
VITAL SIGNS: Revealed a blood pressure of 104/72, pulse 72, oxygen saturation 97% on room air.
GENERAL: The patient is alert, oriented, pleasant and friendly. She is in no acute physical distress.
HEENT: NCAT. Scalp appears healthy without lesion. Hair is rather brittle. Pull test does reveal that multiple hairs do come out with root bulb intact. There are no patches of alopecia noted. Conjunctiva without pallor. Oropharynx benign.
NECK: Supple. No lymphadenopathy. No thyromegaly.
CHEST: Lung sounds clear to auscultation.
CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender. No guarding, rebound, masses.
EXTREMITIES: Without edema.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with approximately 6-month history of mild hair loss. We discussed various causes for this, including iron deficiency anemia, thyroid disorder, stress, or possibly the new medication. We will check some routine labs to rule out a metabolic cause for her hair loss.
I, otherwise, advised her to discuss this with the physician who prescribed her this medication, though she states that she would ultimately like to stay on lamotrigine even if this were proven to be the cause of her symptoms, which would likely be difficult. We will communicate regarding results of her labs once available, and she will return for followup with me in approximately 3 months to reevaluate, being sure to see her gynecologist in the interim for her preventative studies.
We will also help her arrange her mammogram at today’s visit and follow up according to the result. The patient is agreeable with this plan.
