Colon Surgery General Template

Thank you for referring Ms. Carter, a female, who reports persistent fatigue over the last three months, significantly affecting her ability to work and care for her children. She also reports associated symptoms of weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and feeling unusually cold. Her mother has a history of Hashimoto’s thyroiditis.

- She reports persistent fatigue for three months, impacting daily activities and childcare.
- Associated symptoms include weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and feeling unusually cold.
- Family history is significant for Hashimoto’s thyroiditis in her mother.

Past medical history:

Past surgical history:

Medications:

Allergies:

Physical Examination:

Assessment:
The most likely cause of the patient’s symptoms is autoimmune thyroiditis (E06.3), as indicated by elevated TSH, low-normal free T4, and positive anti-TPO antibodies. She also has mild Vitamin D deficiency (E55.9).

Plan and Recommendations
1. Initiated levothyroxine 50 mcg daily, to be taken on an empty stomach, ideally 30 minutes before breakfast. Advised that it may take 6–8 weeks to notice the full effect.
2. Thyroid function tests to be rechecked in six weeks to determine if any dose adjustments are needed.
3. Recommended Vitamin D supplementation at 2000 IU daily and advised rechecking Vitamin D levels in three months. Suggested increasing sunlight exposure.
4. Discussed dietary and lifestyle recommendations, emphasizing a balanced diet and regular light physical activity to help improve energy levels and mood.
5. Instructed to avoid taking thyroid medication simultaneously with calcium or iron supplements, as this may interfere with absorption.
6. Prescriptions have been sent electronically, and a follow-up appointment will be scheduled to ensure continuity of care.

Sincerely,  
Dr. Jamie Lin