Follow-up for Acute Kidney Injury and Hypertension Post Type B Aortic Dissection

Ms. Emily Carter was seen in the office on February 8, 2026, for ongoing management of hypothyroidism in the setting of a family history of autoimmune thyroid disease. She attended the appointment alone. I did not meet her prior to this outpatient visit and was not involved with her care as an inpatient.

In person appointments are now being offered to all patients, but due to the COVID-19 pandemic, I am still providing the option of a virtual consult via videoconference if preferred. Telephone consults are only being provided where there is no other feasible option at present.

Subjective:
Medical History:
- Hypothyroidism, likely autoimmune in origin (supported by elevated thyroid-stimulating hormone, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies)
- Mild vitamin D deficiency
- Family history of Hashimoto’s thyroiditis (mother)

Past Surgical History:
No past surgical history provided.

History of Presenting Illness:
Ms. Carter presents with a three-month history of persistent fatigue that has impacted her ability to work and care for her children. She reports associated symptoms including weight gain, irregular menstrual cycles, and morning joint stiffness. She also endorses hair thinning, constipation, and increased sensitivity to cold. There is a family history of Hashimoto’s thyroiditis in her mother. Laboratory evaluation performed last week reveals an elevated thyroid-stimulating hormone level of 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies, consistent with hypothyroidism of likely autoimmune etiology. Additionally, she is noted to have mild vitamin D deficiency. No other symptoms are reported apart from those described above.

Review of Systems:
- General: Persistent fatigue for three months
- Endocrine: Weight gain, irregular menstrual cycles
- Musculoskeletal: Morning joint stiffness
- Dermatologic: Hair thinning
- Gastrointestinal: Constipation
- Other: Increased sensitivity to cold
- No mention of hair thinning, constipation, or feeling unusually cold being absent

Current Medications:
- Levothyroxine: 50 micrograms orally once daily
- Vitamin D: 2000 international units orally once daily

Known Allergies:
None Known.

Social History:
- Alcohol intake: No information available
- Smoking history: No information available
- Family support: Ms. Carter reports caring for her children
- Living situation: No information available

Lifestyle Notes:
- Diet: Advised to maintain a balanced diet
- Exercise: Advised to engage in regular light physical activity

Chief Complaint:
Fatigue and associated symptoms

Family History:
Ms. Carter's mother has a history of Hashimoto's thyroiditis.

Objective:
Physical Examination:
No physical examination findings documented.

Laboratory Examination:
- Thyroid-stimulating hormone: 7.8 (elevated)
- Free thyroxine: Low-normal
- Anti-thyroid peroxidase antibodies: Positive
- Vitamin D: Mild deficiency

Assessment and Plan:
Impression and Plan:
1. Hypothyroidism, likely autoimmune (Hashimoto’s thyroiditis) (E06.3): Initiate levothyroxine 50 micrograms orally once daily. Reassess thyroid function tests in six weeks to guide dose adjustment.
2. Vitamin D deficiency (E55): Begin vitamin D supplementation at 2000 international units orally once daily. Recheck vitamin D level in three months.
3. Joint stiffness (M25.6): Monitor symptoms; consider rheumatology referral if persistent.
4. Lifestyle: Counsel on balanced diet, regular light exercise, and proper administration of levothyroxine (on an empty stomach, separate from calcium or iron supplements).
- Follow-up: Schedule laboratory reassessment in six weeks for thyroid function and in three months for vitamin D status.

- Autoimmune Hypothyroidism (E06.3): Ms. Carter presents with laboratory findings of elevated thyroid-stimulating hormone, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies, consistent with autoimmune hypothyroidism. She reports persistent fatigue, weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold.
Plan:
• Initiated levothyroxine 50 micrograms orally once daily, to be taken on an empty stomach at least 30 minutes before breakfast.
• Advised to avoid concurrent intake of calcium or iron supplements with levothyroxine.
• Scheduled repeat thyroid function tests in six weeks to assess response and adjust dosage as necessary.
• Provided education regarding the expected timeline for symptomatic improvement (6–8 weeks) and the importance of medication adherence.
• Discussed that joint stiffness is likely related to hypothyroidism; will monitor and consider referral to rheumatology if symptoms persist.
• Recommended a balanced diet and regular light physical activity to support energy and mood.
• Arranged electronic prescription and follow-up appointment scheduling.

- Vitamin D Deficiency (E55.9): Laboratory evaluation revealed mild vitamin D deficiency.
Plan:
• Recommended cholecalciferol (vitamin D3) 2000 international units orally once daily.
• Advised to increase sunlight exposure as tolerated.
• Planned to recheck vitamin D levels in three months.

I will see Ms. Carter in follow-up in six weeks. I have arranged for repeat thyroid function tests at that time and vitamin D reassessment in three months. If you have any concerns prior to the next appointment, please do not hesitate to contact my office. Thank you for involving me in this pleasant patient’s care.

Clinic Name: Regional Medical Center