EDM Thyroid Consult Note

OVERALL_INSTRUCTIONS

Chief Complaint

Evaluation of thyroid dysfunction or thyroid nodule

Template

Date: [Insert Date] Referring Physician: Dr. [Insert Referring Physician Last Name] Dear Dr. [Insert Last Name], Thank you for asking me to see your patient. HISTORY OF PRESENT ILLNESS: Accuro presents for evaluation of [thyroid dysfunction|thyroid nodule] - Patient was found to have [thyroid nodules|abnormal TFTs] [when patient presented with symptoms of|on routine lab evaluation] - History of recent upper respiratory tract infection/recent sickness: [yes|no] - Neck swelling: [yes|no] - Compressive symptoms: dysphagia - [yes|no], dyspnea - [yes|no], dysphonia - [yes|no] - Family history of thyroid cancer: [yes|no] - History of radiation exposure to head and neck: [yes|no] - [Uses|does not use|unsure if uses] iodized salt Symptoms: - Energy level: [low|normal] - Weight change: [stable| ] - Anxiety/depression: [none| ] - Heat/cold intolerance: [none| ] - Tremors: [none| ] - Palpitations: [none| ] - Diarrhea/constipation: [none| ] - Hoarseness: [none| ] - Menstrual irregularity: [none| ] - Eye irritation/tearing: [none| ] Review of systems is otherwise negative. LABORATORY RESULTS: [Thyroid imaging | US: | Scan/uptake/: |null] FAMILY HISTORY: None Recorded LIFESTYLE NOTES: None Recorded PHYSICAL EXAMINATION: The head and neck exam was unremarkable. The patient was euthyroid to physical exam. The thyroid gland was palpable and mobile, normal size, non-tender and with no nodularity. There was no associated neck adenopathy. [There was no orbital stare, lid lag or exophthalmos. The skin temperature and texture were normal| ] The chest was clear to auscultation. Cardiovascular examination showed normal rate and heart sounds, with no audible murmurs or bruits. There was no pretibial myxedema. The abdomen was soft with no palpable organomegaly. Neurological exam showed no tremors and normal deep tendon reflexes. ASSESSMENT AND PLAN: {Hypothyroidism. Patient likely has Hashimoto's thyroiditis resulting in hypothyroidism. I discussed the need for thyroid replacement in hypothyroidism and the risks of over replacement. TSH [ ] target. - Instruction for patient for thyroid hormone replacement - Take thyroid medication on an empty stomach (at least 30-60 mins prior to, or at least 2 hours after food intake). Recommended taking iron/calcium/multivitamin supplementation at least 4 hours apart from the thyroid medication| I have asked Accuro to notify me immediately if she plans to conceive or becomes pregnant. Generally if TSH is at goal pre-conception, the thyroxine dose should be increased by 25-30% upon discovering pregnancy to maintain TSH levels at goal. | I discussed treatment targets during pregnancy for optimal pregnancy and fetal neurocognitive development. Pre-conception and first trimester: TSH target 0.3-2.5 mmol/L. Second and third trimesters: TSH target 0.3-3.0 mmol/L. | Subclinical hypothyroidism and pregnancy Hypothyroidism- Patient is [ ] weeks POG. Patient is clinically euthyroid. TSH was slightly elevated in [ ]. I reviewed ATA 2017 guidelines for treatment of thyroid disease in pregnancy. Patient is not at high risk for thyroid dysfunction or high risk pregnancy. - I will risk stratify patient with a TPO antibody test to determine cut-off for T4 replacement. - I will repeat TFTs at this time to determine if pharmacotherapy is needed.| Thyrotoxicosis/thyroiditis. Patient may have Graves disease vs. Subacute thyroiditis vs toxic adenoma. [US findings were suggestive of [ ]. However US findings can be non specific]. I also discussed the differential diagnoses of Graves’ disease and of an autonomous (toxic) thyroid nodule. - I have not initiated antithyroid medication at this time. - I have [started beta-blocker|not started a beta-blocker as patient does not have tachycardia/palpitations] - I will repeat TFTs at this time to evaluate for persistent hyperthyroidism. - If patient's T4 and T3 continue to be elevated, I will consider further evaluation for Graves' disease and toxic adenoma - If TFTs are normal or show low free T4/T3, patient likely had an episode of thyroiditis. Patient will need to be monitored for hypothyroidism with subsequent periodic lab investigations until TFTs are stable. - I discussed the natural course of subacute thyroiditis: a brief 6-12 week phase of hyperthyroidism, followed by 3-6 months of hypothyroidism, with a subsequent gradual return to a euthyroid state in nearly all patients, with less than 10% developing permanent hypothyroidism. - I also discussed symptoms of hyperthyroidism and hypothyroidism. Accuro will return sooner if symptoms of hyperthyroidism or hypothyroidism develop.| Graves' disease. Patient likely has Graves' disease based on symptoms, lab findings and results of the uptake and scan. - start - start beta-blocker - natural history of disease and long term treatment options discussed. [We discussed potential side effects of methimazole/propyluracil including neutropenia (symptoms: fever, painful mouth and throat and the appropriate response: stop medication and seek emergency help to assess the CBC; hepatitis (symptoms; periodic LFT monitoring); and allergic reaction such as pruritic rash].| Thyroid Nodules. Patient has [ ] nodule. Thyroid nodules were reviewed – including prevalence, natural history, and the general risk of malignancy of ~5%. I reviewed the ACR TI-RADS criteria for thyroid ultrasound in stratifying risk of malignancy. [- I have ordered US-guided fine needle aspiration (FNA) as per ACR TI-RADS criteria] [ - FNA not indicated as per ACR TI-RADS criteria] [I have ordered a follow up US for monitoring in ]|} FOLLOW-UP: Follow up appointment planned in: [1 week | 2 weeks | 3 weeks | 4 weeks | 5 weeks | 6 weeks | 8 weeks | 2 months | 3 months | 4 months | 5 months | 6 months | 1 year | 2 years | Patient is being discharged to your continuing care. I remain available for future reassessment at your discretion. | Per your request, we haven’t booked a follow up visit but I would be happy to see your patient again, for continuing support, at your discretion. | With your permission, I would like to schedule 1-2 further follow up visits to assess the outcomes of the above steps. I’ll then remain available for future reassessment at your discretion. | Patient will be contacted for follow up.] Thank you very much for the opportunity to share in the care of your patient. Sincerely, [Insert Consulting Physician Name and Credentials]