Follow up visit for Hypothyroidism

Medical Record 2:

Patient Information

• Name: [Patient's Name]
• Date of Birth: [Patient's DOB]
• Sex: Female
• Medical Record Number: [MRN]

-Date of Service: 04-07-2024

Chief Complaint

Hypothyroidism

History of Present Illness

45-year-old female presents for a return visit to the endocrine clinic. Since her last visit six months ago, the patient's health has remained stable. She reports fatigue throughout the day but states that she wakes up feeling refreshed with CPAP therapy. She denies signs or symptoms of thyroid excess or hypothyroidism. No temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation, or diarrhea. Weight has been stable, and no proximal muscle weakness reported.

Current Medications: Levothyroxine 125 micrograms p.o. once daily, CPAP, Byetta injected twice daily, Synthroid, Avandamet, Glucotrol.

ROS: As stated in the HPI. Denies polyuria, polydipsia, or polyphagia. No fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation, or diarrhea. No lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea, or dyspnea on exertion.

Physical Examination

• General: Overweight, pleasant woman, in no acute distress.
• Vital Signs: Temperature 96.9°F, pulse 85 bpm, blood pressure 135/65 mmHg, weight 85.7 kg.
• Neck: Well-healed surgical scar, no palpable thyroid tissue or lymphadenopathy.
• Thorax: Lungs clear, PA and lateral, without adventitious sounds.
• Cardiovascular: Regular rate and rhythm, no murmurs.
• Extremities: Deep tendon reflexes 2+/4 without delayed relaxation phase, no tremors.
• Skin, Hair, and Nails: Unremarkable.

Laboratory Data

04/06/2024: Thyroglobulin quantitative <0.5, thyroglobulin antibody <20, free T4 1.35, TSH suppressed at 0.121.

Assessment and Plan

1. Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.

• Plan to continue following thyroglobulin levels.
• Obtain free T4, TSH, and thyroglobulin levels today.
• Patient to call clinic next week for follow-up and continued management of hypothyroid state.

2. Taper medication to achieve TSH <0.41.

• Repeat thyroid function studies done today.

3. Follow-up in approximately 6 months or sooner.

• No repeat body scan planned; previous one in 03/06 was negative.

Provider's Signature: electonically signed by Dr. XYZ, MD, Date: 04/07/2024