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MH
K. Joller
F, 41 · Consultation #3
Transcribing
Live transcript
Patient reports recurring fatigue for the past three weeks, worse in the mornings. No fever. Sleep quality disrupted, averaging 5–6 hours…
SOAP Note
AI DRAFT
S
Fatigue x3 weeks, morning predominance, poor sleep, no fever.
O
BP 118/74, HR 72 bpm, SpO₂ 98%. Appears fatigued, alert.
A
Suspected subclinical hypothyroidism or insomnia-related fatigue.
P
Order TSH, FBC. Sleep diary. Follow-up in 2 weeks.
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