Nephrology Follow-Up Template

Patient was reviewed in follow-up in person in the office on 2026-01-22 for ongoing management of her persistent fatigue. Accompanied by her children.

In-person appointments are now being reintroduced based on acuity and patient preference. Due to the COVID-19 pandemic, we are still providing the option of a virtual appointment.

Medical History:
- Autoimmune thyroiditis (Hashimoto’s thyroiditis) - Diagnosed 2026, based on elevated TSH, low-normal free T4, and positive anti-thyroid peroxidase antibodies
- Vitamin D deficiency, mild - Diagnosed 2026

Past Surgical History:

Clinical Update:
Ms. Taylor presents with a three-month history of persistent fatigue, recent weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold. Family history is notable for Hashimoto’s thyroiditis in her mother. Laboratory investigations revealed elevated TSH (7.8), low-normal free T4, and positive anti-thyroid peroxidase antibodies, consistent with autoimmune hypothyroidism. Mild vitamin D deficiency was also noted. She denies other symptoms at this time. She is currently not on any medications.

Review of systems:
• Reports persistent fatigue for the past three months and recent weight gain.
• Endocrine: Irregular menstrual cycles, hair thinning, constipation, increased sensitivity to cold.
• Musculoskeletal: Morning joint stiffness.
• Denies other symptoms at this time.

Physical examination:

Current Medications: 
- Levothyroxine 50 mcg daily
- Vitamin D 2000 IU daily

Known Allergies: 
None Known.

Investigations: 
Laboratory examination:
- Thyroid-stimulating hormone (TSH): 7.8 (elevated)
- Free thyroxine (T4): low-normal
- Anti-thyroid peroxidase (anti-TPO) antibodies: positive
- Vitamin D panel: mild deficiency

Imaging: 

Impression and Plan:
1. Autoimmune thyroiditis (Hashimoto’s thyroiditis): Ms. Taylor’s symptoms and laboratory findings are consistent with autoimmune hypothyroidism. She has been started on levothyroxine 50 mcg daily. Thyroid function tests will be rechecked in six weeks to evaluate response and adjust dosage if necessary. She was advised to take her thyroid medication on an empty stomach, ideally 30 minutes before breakfast, and to avoid taking it alongside calcium or iron supplements due to absorption interference. The importance of a balanced diet and regular light physical activity was discussed to help improve energy and mood. Joint stiffness is likely related to hypothyroidism; if it persists, rheumatology referral will be considered.

2. Vitamin D deficiency: Ms. Taylor was started on Vitamin D supplementation at 2000 IU daily. A follow-up Vitamin D panel is planned in three months to assess levels.

Renoprotective measures:
• Avoid nonsteroidal anti-inflammatory medications

PRESCRIPTIONS GIVEN:
• Levothyroxine 50 mcg tablet, oral, once daily
• Vitamin D 2000 IU tablet, oral, once daily

I have waitlisted her for a nephrology follow-up appointment in six weeks time. Ongoing routine renal lab work has been arranged every six weeks. I would appreciate it if you could add me as a copy on her standing order requisition. I will order additional renal lab work as indicated.