Pharmacy - Allergic Rhinitis

PATIENT DETAILS:
Name: Ms. Taylor
Phone number: 
Personal Health Number (PHN): 

GENERAL:
PharmaNet has been checked. 

Objective:
Reason For Visit:
Persistent fatigue.

Patient Assessment:
Ms. Taylor reports persistent fatigue for approximately three months, which impairs her ability to work and care for her children. She describes associated symptoms including weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold. There is a family history of autoimmune thyroid disease, specifically Hashimoto’s thyroiditis in her mother. Laboratory investigations reveal an elevated thyroid stimulating hormone level of 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies. Mild vitamin D deficiency is also noted. On physical assessment, no additional findings are documented.

Subjective:
PAST MEDICAL HISTORY:
No significant findings.

CURRENT MEDICATIONS:
No current medications reported.

ALLERGIES:
No allergies reported.

Assessment:
DIAGNOSIS:
Allergic rhinitis

Plan:
RECOMMENDATIONS:
- Ms. Taylor is educated regarding the diagnosis of hypothyroidism, likely autoimmune in origin, and mild vitamin D deficiency.
- Self care advice: Ms. Taylor is advised to maintain a balanced diet and engage in regular light physical activity to support energy and mood. She is instructed to avoid taking levothyroxine with calcium or iron supplements and to take the medication on an empty stomach, ideally 30 minutes before breakfast. Sunlight exposure is recommended to address vitamin D deficiency.
- Treatment: Initiation of levothyroxine 50 micrograms orally once daily. Vitamin D supplementation at 2000 international units daily is recommended.
- Ms. Taylor is advised that she may need to seek further medical assistance if symptoms persist or worsen, particularly regarding joint stiffness, in which case rheumatology referral may be considered.
- Ms. Taylor has been informed that she can fill her prescription at any pharmacy of her choosing.

MONITORING/FOLLOW UP:
- Follow up in 3-7 days to assess response to treatment.
- 

Date:
2026-02-07

PHARMACY INFORMATION:
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Pharmacy phone number: 
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