Pharmacy - Dermatitis

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

GENERAL:
PharmaNet has been checked. Eligibility not documented.

Subjective:
REASON FOR VISIT:
Persistent fatigue.

PATIENT ASSESSMENT:
Ms. Parker reports persistent fatigue for approximately three months, accompanied by weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and cold intolerance. Family history is notable for maternal Hashimoto’s thyroiditis. Laboratory evaluation reveals elevated thyroid stimulating hormone at 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies, consistent with autoimmune hypothyroidism. Mild vitamin D deficiency is also noted. No occupational exposures or triggers identified. No previous episodes or treatment history reported.

Objective:
PAST MEDICAL HISTORY:
No significant past medical history provided.

CURRENT MEDICATIONS:
No current medications documented.

ALLERGIES:
No allergies documented.

Assessment:
DIAGNOSIS:
Autoimmune hypothyroidism (E06.3) and vitamin D deficiency (E55.9).

Plan:
RECOMMENDATIONS:
- Patient education: Ms. Parker is educated regarding the diagnosis of autoimmune hypothyroidism and vitamin D deficiency, including the importance of medication adherence and lifestyle modifications.
- Self care advice: Ms. Parker 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.
- Treatment: Levothyroxine 50 micrograms orally once daily is prescribed. Vitamin D supplementation at 2000 IU daily is recommended. Ms. Parker is instructed to obtain sunlight exposure as feasible.
- Ms. Parker has been informed that she can fill her prescription at any pharmacy of her choosing.

MONITORING/FOLLOW UP:
- Follow up in six weeks to reassess thyroid function tests and adjust levothyroxine dosage as needed.
- Ms. Parker is advised that if there is no improvement in symptoms or if joint stiffness persists, she should contact her primary care provider for further evaluation, including possible rheumatology referral.
- Provider notified: 

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

DATE:
2026-01-29