ALOPECIA (NON-SCARRING): FOCUSED NOTE

SAMPLE FOCUS NOTE

CHIEF COMPLAINT (C/C)
“I have trouble breathing”

HISTORY OF PRESENT ILLNESS (HPI)
24-year-old single,domicile, Hispanic female presents to the Clinic with complain of difficulty breathing times 3 days. She reported her symptoms began with her having what she considered a common cold 3days,ago andworsened over the next 2 daysresulting in persistent cough, wheezing, chest tightness, increased dyspnea, and severe anxiety.

Patient report that walking up the stairs to her bedroomor doing any type of activity worsen her SOB and chest tightness.  She denies any fever or chills, she denies chest pain but report wheezing accompanied by chest tightness and dyspnea. She denies headache nasal or sinus congestion.

She reports drinkinghot tea andusing an old albuterol pump she had at home with little or no relief. Patient report history of childhood asthma but has not experienced an attack or symptoms in the last sixyears and reports never having experienced this level of severity of symptoms. She denies any know triggers, denies having any pets at home or exposure to cat dander, dust mites or grass or tree pollens.

PAST HISTORY
CHILDHOOD ILLNESSES:

Denies chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.

IMMUNIZATION:
Childhood vaccine

Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018

– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2

HPV Three dose Series completed 2008
Influenza 10/21

COVID vaccine Completed 1/14/21, 2/7//21 and booster dose 9/18/21

ADULT ILLNESS:

Asthma
PSYCHIATRIC ILLNESS:

Denies past or present psychiatric illnesses.

ACCIDENTS or INJURIES:

Denies accidents or injuries
OPERATIONS: Denies
ALLERGIES: No known drug or food allergies.

MEDICATIONS:

Albuterol Ventolin HFA 2 puffs Q 4-6 hours PRN

COMPLIMENTARY TREATMENTS: None

FAMILY HISTORY:
Maternal grandmother: Unknown deceased
Maternal grandfather: Unknown deceased
Paternal grandmother: Unknown deceased
Paternal grandfather: Unknown deceased
Mother Age 50 HTN
Father  Age 52 Asthma
3 siblings/ sisters 21, 16, 8: No Known Medical problems

SOCIAL HISTORY
Education: High school diploma
Occupation: office administrator
Living situation: Lives with parents in private home
Financial: Employed and lives with her parents
Tobacco: None
Alcohol: Socially drinks wine one glass per month
Drugs: Smoke Marijuana occasionally 1 blunt every 3-4 months

Sexual history: Heterosexual, sexually active, one partner
Marital status: Single
Exercises: No formal exercise routine

REVIEW OF SYSTEMS

GENERAL: Well-nourished female, with normal height and weight, who denies fever, chills, body aches, fatigue, night sweats or any changes in sleeping pattern.

HEAD: Denies headache or head injury

EYES:

Denies wearing glasses or contact lens; last vision check,10 months ago; denies pain redness, excessive tearing, double vision, floaters, lost of visual field cataract or glaucoma.

EARS: Denies hearing loss, ringing in the ear’s, earaches, or ear infections.

NOSE AND SINUS: Report having running nose and nasal stuffiness three days ago.  Denies hay fever, nose bleeds, sinus congestion, obstruction, change in the ability to smell. Sneezing postnasal drip or history of polyps.

MOUTH AND THROAT:

Denies, soreness, dryness. Pain ulcers, sore tongue, bleeding gums, pyorrhea, dental carries, sore throat, hoarseness, history of strep throat or recurrent sore throat or rheumatic fever.

RESPIRATORY: Reports nonproductive cough, dyspnea, wheezing, shortness of breath and chest tightness times three days. Used albuterol with no relief. Reports history of childhood asthma with last asthma attack 6 years ago. Denies hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Denies TB or exposure to TB.  Last PPD done 10 months ago and was negative. No history of pneumonia or history of environmental exposure

CARDIAC: Denies chest pain, or palpitations, denies paroxysmal nocturnal dyspnea, denies orthopnea, edema, palpitations, hypertension, known heart disease, rheumatic fever, heart murmurs, rheumatic fever syncope or near syncope, pain in posterior calves.

GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Bowel movement 1-2 times daily, soft brown stool.

PHYSICAL EXAMINATION
VITAL SIGNS: T 98.6 ºF, P68, RR 24, BP 126/70 (right arm, sitting, automatic), 126/68 (right arm, standing, automatic), oxygen saturation 94 % room air, height 5 ft. 6 in., weight 168 lbs. BMI 27.1.
GENERAL SURVEY: Alert and oriented x 3. Appears, fatigued, and anxious.  She is slightly overweight, well-nourished, well-groomed and appears stated age of 24.

HEAD:  Normocephalic, atraumatic, scalp clean, no dandruff, hair short, black, evenly distributed.

EYES: Symmetrical, lids without drooping or ptosis, sclera white, no icterus or muddy appearance, conjunctiva pale, corneal clear, PERRLA, EOM intact, light reflex direct and consensual brisk and intact. Visual acuity 20/20 bilateral.  Optic disc with intact red reflex,optic discwith sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.

EARS: Symmetrical and in line with the outer canthus of the eyes, manipulation of the pinna without tenderness. Ear canals clear, no cerumen observed, tympanic membrane pearly grey with good cone of light bilaterally. Acuity good to whispered voice. Rinne test AC>BC. Weber -midline

NOSE:

Nares congested, with small amount of clear discharge; nasalseptum intact, turbinates’ slightly enlarged and boggy, Frontal and maxillary sinus non tender to palpation and percussion.

THROAT:

LIPS: dry, scaly, tongue midline, moist and without fasciculation; teeth in good repairs, no cavities; gum pink, no gingivitis, oral mucosa pink and moist, no halitosis. Tonsils without erythema and non-edematous, no injection or exudates; uvula midline and moves up and down with pronation.

NECK: Supple, FROM, Thyroid isthmus palpable, smooth, no nodules, mass, or tenderness.  Trachea midline, no stridor, carotid upstroke brisk, no bruit.  No JVD.

RESPIRATORY: Chest Anterior/Posterior thorax symmetrical, normal diaphragmatic excursion: Tactile fremitus diminished, in all lung fields; No tenderness on palpation of anterior and posterior chest. Percussion notes hyperresonance;Lungs with scattered wheezing in all lung fields no rales, rhonchi, or rubs.

CARDIOVASCULAR: No increase carotid pulsation on inspection No visible PMI; No palpable lifts, heaves, or thrill.  PMI palpated at the 5 ICS, MCL; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; JVP-6 CM H2O. Heart sound one (S1) and heart sound two (S2) – normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.

Abdomen: Protuberant, no scars. Bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness Liver span 5-6 cm dullness. No tenderness on light and deep palpation Liver, spleen, and kidneys non-palpable.

PROBLEM LIST
SOB
Chest tightness
Dyspnea
Wheezing

ASSESSMENT
Asthma Exacerbation

Differential Diagnosis
URI
Mild persistent asthma
Rhinitis
Sinusitis
Viral syndrome
COPD

DIAGNOSTIC PLAN:

Diagnostic

Pregnancy test

BMP, CBC

1) PFT
(2) Chest x-ray

Medication

Nebulized treatment albuterol 0.083% 1 dose via nebulizer stat

(1)   Albuterol Ventolin HFA 2 puffs Q 6 hours PRN

(2)    Medrol/ methylprednisolone dose pack as prescribe

REFERRAL:
Pulmonologist

Follow UP in 2 weeks:

PATIENT EDUCATION
You are being diagnosed with asthma exacerbation. Asthma is a chronic inflammatory disorder of the airways characterized by increased responsiveness of the tracheobronchial tree to various stimuli resulting in reversible narrowing and inflammation of the airways.  Symptoms you make experience includes wheezing associated with cough, and sputum production, shortness of breath, chest tightness breathlessness and anxiety.

Your asthma may be precipitated by cat allergen/dander, house dust mites ‘cockroaches as well as trees and pollen. Viral illness, such as in your case, can also induce airway obstruction.  You will continue to take your albuterol inhaler; this is your rescue medication. You will also start using another asthma medication which is a corticosteroid named Medrol, methylprednisolone dose pack.

On day one, you will take 24 mg in four divided dose, every six hours. On day two, you will take 20 mg at the same time schedule of day one. On day three, 16 mg, On day four, 12 mg, On day five 8 mg and on the last day 4 mg.  I am referring you to a pulmonologist to follow up for a chest x-ray and spirometry testing to assess your lung functioning and vital capacity. Continue to exercise as tolerated. Hand washing is important to prevent exposure to additional cold/viruses. Continue your physical activity as much as you can tolerate.If you experience worsening or lingering symptoms, do contact the medical office, or call 911 immediately.

FOCUSED NOTE: ALOPECIA (NON-SCARRING)

CHIEF COMPLAINT (C/C)
“I have mild itching on my scalp. The itchiness began at one focal point but it is spreading to other areas. I feel like I have lost hair in some regions of the scalp. The itchy areas are painful with non-scaly patches due to persistent scratching.”

HISTORY OF PRESENT ILLNESS (HPI)
A 42-year-old white female patient has reported to the clinic complaining of pruritus and diffusing hair loss on the scalp. The pruritus and hair loss have persisted for the past two weeks. As reported by the patient, her symptoms started like a simple scratch on a focal area of the scalp but it has since spread to other areas characterized by hair loss.

She further reports that areas of hair loss have non-scaly patches which do not resolve even by washing. The patient denies using any oral or topical medications to treat her current symptoms. She further indicates that cold weather aggravates the itchiness which is relieved during hot weather. She reports undergoing distress in the past one month due to personal life issues.

PAST HISTORY
CHILDHOOD ILLNESSES:

Does not report a history of chickenpox measles, mumps, rubella, whooping cough, rheumatic fever, scarlet fever, or polio.

IMMUNIZATION:
Childhood vaccine

Immunization
– Hepatitis B: 3/3
– Diphtheria, Tetanus, and Pertussis: 5/5
– Booster dose of TDAP 2018

– Hemophilus influenza type B: 4/4
– Pneumococcal conjugate: 4/4
– Inactivated Polio- virus- 4/4
– Measles, Mumps, Rubella: 2/2

HPV Three dose Series completed 2000
Influenza 12/21

COVID vaccine Completed 11/13/21, 3/15/21. She has not received a booster dose for COVID vaccine.
ADULT ILLNESS: Denies a serious medical condition during adulthood.
PSYCHIATRIC ILLNESS: Denies past or present psychiatric illnesses.
ACCIDENTS or INJURIES: Denies accidents or injuries
OPERATIONS: Reports undergoing operation during child birth at the age of 25 years. The patient reports undergoing a caesarian section when she was giving birth to her twins 17 years ago.
ALLERGIES: No known drug or food allergies.
MEDICATIONS: The patient denies using any medications at the moment.
COMPLIMENTARY TREATMENTS: None
FAMILY HISTORY: Father died of stroke at the age of 76 years. Mother is 66 years old. She is currently alive and was diagnosed with Type 2 diabetes mellitus 5 years ago. Her diabetes is well-controlled. The patient has three brothers aged 37 years, 34 years, and 32 years and one sister aged 20 years. All her siblings are healthy. Both maternal and paternal grandparents are deceased. The causes of their death are unknown.

SOCIAL HISTORY
Education: A university graduate
Occupation: Accountant
Living situation: Lives with her kids in a rental house
Denies a history of childhood asthma. Denies a history of hemoptysis, bronchitis, emphysema, pneumonia, tuberculosis, or pleurisy. Does not report TB or exposure to TB. Last physical check-up for pulmonary function was five years ago. Denies a history of pneumonia or a history of exposure to chemicals.
CARDIAC: Denies chest pain, or palpitations. Denies paroxysmal nocturnal dyspnea. Does not report orthopnea, edema, palpitations, hypertension, or known heart disease. Denies rheumatic fever, heart murmurs, or pain in posterior calves.

GASTROINTESTINAL: Denies abdominal pain, trouble swallowing, heartburn, problem with appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion, food intolerance, excessive belching, burping, or passing of gas; denies constipation, diarrhea, jaundice, liver or gallbladder trouble, hepatitis. Reports soft brown stool with bowel movements occurring 1-2 times daily.

PHYSICAL EXAMINATION

VITAL SIGNS: BP: 117/73 (sitting, automatic), P: 98, RR: 20, T: 37.6 Ht: 58 inches Wt: 154 lbs; BMI: 24.3 (the patient indicates that this ranges within her usual weight).
GENERAL SURVEY: Alert and oriented to time, person, and place. Evidence of acute distress and fatigue. Well nourished. The patient’s appearance is appropriate for the stated age.
SKIN: Skin is smooth, warm, dry, and intact without rashes, or lesions. Nail beds are pink with no evidence of clubbing or cyanosis.
HEAD:  The head is normocephalic and atraumatic. Hair is short. There is evidence of hair loss in some areas of the scalp. Areas of hair loss appear non-scaly. There is also evidence of hair thinning and broken hair shafts in the regions that surround regions of hair loss on the scalp. There is uneven distribution of hair on the scalp. The remaining hair is black in color. Hair texture is soft. There is no evidence of scarring on the areas of hair loss.

EYES: Clear conjunctivae on both eyes. Both eyes are symmetrical. Lids are without drooping or ptosis. Both sclerae are white. No evidence of hemorrhage or exudates. No icterus or muddy appearance on the sclerae, conjunctivae are pale, corneal clear, PERRLA, EOM are intact, light reflex direct and consensual brisk and intact. No swellings of lesion on eye lids. Visual acuity 20/20 bilateral.  Optic disc with intact red reflex, optic disc with sharp margin, small central cup, and no edema. Retinal vessels intact, no A/V nicking or cotton wool spots.

EARS: Internal and external ears are without edema or tenderness. Both ears are symmetrical and are in line with the outer canthus of the eyes. The pinna can easily be manipulated without difficulties. Rinne test AC>BC. No evidence of obstruction of the ear canals. No evidence of cerumen observed. The tympanic membrane IS pearly grey with good cone of light bilaterally. Weber -midline. Acuity good to whispered voice.

NOSE: Nasal mucosa is moist and pink. No evidence of discharge or nasal congestion. Turbinates are neither boggy nor enlarged. The sinuses are non-tender. The nasal septum is intact and positioned midline.

MOUTH AND THROAT: The buccal mucosa is moist. The tongue is positioned midline, moist, pink, and without fasciculation. The teeth in good arrangements on the gums. No evidence of cavities. The gum is pink with no evidence of gingivitis or halitosis. No tonsils or erythema observed on the throat. No exudates, lesions, or nodules. The pharynx is pink in appearance.
NECK: The trachea is positioned midline. The neck is supple with no adenopathy observed. Thyroid gland is normal without masses. Palpable thyroid isthmus. Carotid pulse 2+ bilaterally without bruit. No jugular vein distention (JVD). No stridor observed.
RESPIRATORY: Normal diaphragmatic excursion. The chest wall is symmetric and without deformity. No tenderness on palpation of anterior and posterior chest. No signs of trauma observed. No evidence of respiratory distress. Clear lung sounds in all lobes of the lungs bilaterally without wheezes, rales, or Ronchi. Normal Resonance on percussion of all lung fields.
CARDIOVASCULAR: The external chest is normal in appearance without palpable lifts, heaves, or thrills. Invisible PMI and is palpated in the 5th intercostal space at the midclavicular line. Normal heart rate and rhythm. No murmurs, rubs, or gallops. S1 and S2 are heard and are of normal intensity.

No increase carotid pulsation on inspection; No carotid bruit auscultated; Bilateral carotid upstrokes brisk without bruits. No increase jugular venous pulsations; Heart sound one (S1) and heart sound two (S2)-normal; No S3 or S4; No murmurs, rubs, heaves, or gallops.

ABDOMEN: Abdomen is soft and protuberant, no scars. Normal bowel sounds active in all four quadrants; No abdominal guarding, or tenderness; Percussion notes tympanic in all four quadrants. No shifting dullness. No tenderness on light and deep palpation Liver, spleen, and kidneys non-palpable. Umbilicus is midline with no evidence of herniation. No abnormal masses observed.

PROBLEM LIST
Mild pruritus or itching on the scalp

Sudden hair loss

Diffuse hair loss on the scalp

Non-scaly patches on regions of hair loss on the scalp

Absence of scarring in the affected areas of the scalp

Hair thinning/broken hair shafts

Areas of hair loss are non-erythematous
ASSESSMENT
Alopecia (non-scarring)

DIFFERENTIAL DIAGNOSIS
Trichotillomania

Lichen planopilaris

Stress

Anemia
DIAGNOSTIC PLAN:

Diagnostics

-Pregnancy test

-Psychological assessment to determine the degree of stress, the source of a stressful events, and use of hair products

-Pull test to establish whether there is evidence of active hair shedding

MEDICATION

-Intralesional triamcinolone acetonide injected intradermally

-2% solution of topical minoxidil

REFERRAL:
-Psychiatrist

-Gynecologist

-Dermatologist

Follow UP in 2 weeks:

PATIENT EDUCATION

Your primary diagnosis is non-scarring type of alopecia. Alopecia is a disease condition in which patients present with hair loss on the scalp. It is called nonscarring type because there is lack of scars on the areas of hair loss. Non-scarring alopecia may be triggered by numerous factors including stress, exposure to chemical agents, use of strong hair products, hormonal imbalance, or pregnancy-related reactions in women (Poonia et al., 2020).

Non-scarring alopecia is reversible, especially when appropriate treatment is started early. Patients with non-scarring alopecia usually experience mild itchiness on the scalp characterized by hair loss which may be focal or diffuse. Hair thinning and softness are additional symptoms that are usually experienced by people non-scarring alopecia. In non-scarring alopecia, regions of hair loss can form non-scaly patches but are usually non-erythematous.

Your alopecia may be attributed to a recent event of stress that are reportedly experiencing, hormonal changes, some cosmetic products that you are currently using on your hair, or exposure to some chemical agents that you might not be aware of (Oner & Akdeniz, 2021). Such substances usually cause hair non-scarring hair loss, especially in females You will be treated with intralesional triamcinolone acetonide intradermally to help relieve disease symptoms (American Academy of Family Physicians, 2020; Kapoor et al., 2020).

You will also be given a 2% solution of topical minoxidil that you will be required to apply on your scalp twice a day for two weeks before visiting the hospital again (Wall et al., 2022). You will be referred today to a psychiatrist to assess the level and potential impact of your stress. Additionally, you will need to visit a dermatologist who should conduct a further assessment to establish possible causes of your alopecia and to recommend the most appropriate interventions.

You will also need to visit a gynecologist to assess if there is an imbalance in the levels of your sex hormones. You are advised to engage in physical activity and consume a diet that is rich in proteins, fruits, and vegetables (Trueb, 2021). Feel free to reach the clinic using the number provided in your forms if you experiencing problematic symptoms.

References

American Academy of Family Physicians. (2020). Hair loss: Common causes and treatment. https://www.aafp.org/afp/2017/0915/p371.html

Kapoor, P., Kumar, S., Brar, B. K., Kukar, N., Arora, H., & Brar, S. K. (2020). Comparative evaluation of therapeutic efficacy of intralesional injection of triamcinolone acetonide versus intralesional autologous platelet-rich plasma injection in alopecia areata. Journal of Cutaneous and Aesthetic Surgery, 13(2), 103–111. https://doi.org/10.4103/JCAS.JCAS_16_19

Öner, Ü., & Akdeniz, N. (2021). Nonscarring scalp alopecia: Which laboratory analysis should we perform on whom? Turkish Journal of Medical Sciences, doi: 10.3906/sag-2106-28. Epub ahead of print. PMID: 34688244.

Poonia, K., Thami, G. P., Bhalla, M., Jaiswal, S., & Sandhu, J. (2020). Non-scarring diffuse hair loss in women: a clinico-etiological study from tertiary care center in North-West India. Journal of Cosmetic Dermatology, 18(1):401-407. doi: 10.1111/jocd.12559. Epub 2018 May 17. PMID: 29774652.

Trüeb R. M. (2021). “Let Food be Thy Medicine”: Value of nutritional treatment for hair loss. International Journal of Trichology, 13(6), 1–3. https://doi.org/10.4103/ijt.ijt_124_20

Wall, D., Meah, N., Fagan, N., York, K., & Sinclair, R. (2022). Advances in hair growth. Faculty Reviews, 11, 1. https://doi.org/10.12703/r/11-1