Pharmacy-- Conjunctivitis

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Subjective:
REASON FOR VISIT:
Persistent fatigue.

ASSESSMENT:
Ms. Parker reports persistent fatigue for approximately three months. Additional symptoms include 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 (mother with Hashimoto’s thyroiditis). Laboratory investigations reveal elevated thyroid stimulating hormone at 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies. Mild vitamin D deficiency is also noted.

Objective:
PAST MEDICAL HISTORY:
No significant findings.

CURRENT MEDICATIONS:
No current medications reported.

ALLERGIES:
No allergies reported.

Assessment:
DIAGNOSIS:
Conjunctivitis

Plan:
RECOMMENDATIONS:
- Ms. Parker is educated regarding the diagnosis of autoimmune hypothyroidism and mild vitamin D deficiency.
- Self care advice: Ms. Parker is advised to maintain a balanced diet, engage in regular light physical activity, and ensure adequate sunlight exposure for vitamin D. 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.
- Treatment: Initiate levothyroxine 50 micrograms orally once daily. Initiate vitamin D supplementation at 2000 international units daily.
- Ms. Parker has been informed that she can fill her prescription at any pharmacy of her choosing.

MONITORING/FOLLOW UP:
- Follow up in 6 weeks to reassess thyroid function and adjust levothyroxine dosage as needed. Recheck vitamin D level in 3 months.
- 

Date:
2026-02-01

PHARMACY INFORMATION:
Pharmacy name: 
Pharmacy phone number: 
Pharmacy address: 
Pharmacist name: 
Pharmacist license number: