Endo Thyroid Follow Up - Adult

Subjective:
Chief Complaint:
Follow-up for hyperthyroidism

History of Present Illness:
Emily Chen is a patient presenting for follow-up of hyperthyroidism treatment. She has been on antithyroid medication, currently taking 5 mg twice daily. Since the last visit, she reports improvement in her symptoms overall. However, she mentions experiencing generalized itching, which she suspects may be related to the medication. She denies symptoms of hypothyroidism such as tachycardia, weight loss, or tremors. She has not recently used any antihistamines for the itching, though she recalls using such medication approximately six months ago for an unrelated issue. Her recent thyroid function tests show a decrease in T4 levels from 42 to 26.7, and her T3 level is currently 14.5, which remains above the normal range. She prefers to continue with the current medication dosage and will follow up in six weeks for further evaluation.

Past Medical History:
Emily Chen has a history of hyperthyroidism, currently under treatment with antithyroid medication. No other thyroid-related conditions such as thyroid nodules, thyroid cancer, Graves' disease, or Hashimoto's thyroiditis are mentioned.

The Review of Systems:
Constitutional – no fever, chills, weight loss, weight gain, night sweats, fatigue, or weakness. Eyes – no double vision, no blurry vision, wears glasses, no dry eyes. Integumentary – generalized itching reported, no rashes, dry skin, or eczema, no increased sweating. Cardiovascular – no chest pain, heart palpitations, dizziness. Respiratory – no shortness of breath, no cough, no wheezing. Gastrointestinal – no nausea, vomiting, diarrhea, or constipation. No problems swallowing. No abdominal pain or bloating. Genitourinary – no dysuria, hematuria, frequency, urgency. No changes to menstruation, no changed libido. Musculoskeletal – no muscle aches, muscle weakness, joint tenderness, redness or swelling. Neurological – no tremor, no headaches or weakness, no sensory changes, no numbness or tingling in hands/fingers, no history of seizures. Psychology – no changes in mood, no anxiety, no sleep disturbances, no irritability, impaired concentration.

Allergies:
No known drug, food, or environmental allergies reported.

Current Medications:
Emily Chen is currently taking 5 mg of Tapazole twice daily for hyperthyroidism. No allergic reaction medications like Reactine have been taken recently for the reported itching.

Past Surgical History:
Not mentioned

Assessment:
Problem:

1. Hyperthyroidism (242.90) with elevated T3 levels and generalized itching, possibly related to medication.

Clinical Impression:
Hyperthyroidism (242.90) with improving T4 levels but persistently elevated T3 levels. Generalized itching, possibly related to Tapazole medication.

Objective:
Physical Examination:
Constitutional – patient is alert and appears well, in no acute distress. HEENT – head atraumatic and normocephalic, EOMI, PERRLA, no oral lesions. Neck – Thyroid not enlarged, feels soft and symmetrical with no palpable nodules, no tenderness, normal movement on swallowing. No lymphadenopathy, trachea midline. Cardiovascular – regular rate and rhythm, normal heart sounds with no murmurs or added sounds, no jugular venous distension. No peripheral edema, capillary refill time <2s. Respiratory – clear to auscultation bilaterally, no wheezes or crackles. Abdomen – soft, non-tender, no distension, no hepatosplenomegaly, normal bowel sounds. Neurologic – strength 5/5 in upper and lower extremities, normal gait, cranial nerves grossly intact. Integumentary – generalized itching noted, no signs of dry skin, hair or nail brittleness, no hair loss, no rashes, lesions, or other significant skin changes.

Test Results:
Recent thyroid function tests show a decrease in T4 levels from 42 to 26.7. T3 level is currently 14.5, which remains above the normal range (upper limit 5.8).

Vital Signs:
Temperature: , Pulse: , Respiratory rate: , Blood pressure: , Oxygen saturation: , Weight: , Height: , BMI: 

Plan:
We will repeat thyroid function tests in six weeks to monitor T3 and T4 levels. The patient is to continue taking Tapazole 5 mg twice daily as prescribed. I have advised Emily Chen to monitor for symptoms of itching and, if they worsen, consider using an over-the-counter antihistamine such as Reactine. We discussed the potential for allergic reactions to Tapazole and emphasized the importance of adhering to the current medication regimen. A follow-up appointment has been scheduled in six weeks to reassess thyroid function and evaluate any changes in symptoms.

Follow Up:
Next appointment scheduled for July 2nd at 2:30 PM.

Assessment and Plan:
- Hyperthyroidism (242.90): Emily Chen presents for follow-up of hyperthyroidism treatment. Her thyroid function tests show improvement with a reduction in T4 levels from 42 to 26.7. However, her T3 level remains elevated at 14.5, above the normal range. She reports generalized itching, which may be related to her current medication, Tapazole (5 mg twice daily). She denies symptoms of hypothyroidism such as tachycardia, weight loss, or tremors.
Plan:
• Continue current dosage of Tapazole at 5 mg twice daily.
• Advised the patient to monitor for worsening itching or other allergic reactions. If symptoms become intolerable, she may take over-the-counter antihistamines such as Reactine, up to twice daily, to alleviate symptoms.
• Educated the patient about the potential side effects of Tapazole, including the possibility of allergic reactions such as itching or rash.
• Scheduled follow-up in six weeks to reassess thyroid function and medication tolerance. The follow-up is set for July 2nd at 2:30 PM.

- Generalized Pruritus (698.9): Emily Chen reports generalized itching, which she suspects may be related to her medication. She denies seasonal triggers or a prior history of significant itching.
Plan:
• Advised the patient to monitor the severity of itching and consider using over-the-counter antihistamines such as Reactine if symptoms worsen.
• Discussed the possibility of medication-related allergic reactions and emphasized the importance of reporting any new or worsening symptoms promptly.