Pharmacy - Dyspepsia

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

GENERAL:
PharmaNet has been checked. Eligibility documented.

Objective:
REASON FOR VISIT:
Persistent fatigue.

PATIENT ASSESSMENT:
Ms. Parker reports persistent fatigue for approximately three months. Additional reported symptoms include weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold. Family history is significant for maternal Hashimoto’s thyroiditis. Laboratory assessment reveals elevated thyroid stimulating hormone at 7.8, low-normal free thyroxine, and positive anti-thyroid peroxidase antibodies. Mild vitamin D deficiency is also noted.

Subjective:
PAST MEDICAL HISTORY:
No significant findings.

CURRENT MEDICATIONS:
No current medications reported.

ALLERGIES:
No allergies reported.

Chief Complaint:
Persistent fatigue

Assessment:
DIAGNOSIS:
Dyspepsia (K30)

Plan:
RECOMMENDATIONS:
- Ms. Parker was provided education regarding hypothyroidism and vitamin D deficiency.
- Lifestyle modifications: Patient advised to maintain a balanced diet and engage in regular light physical activity to support energy and mood.
- Levothyroxine 50 micrograms orally once daily prescribed. Instruction to take on an empty stomach, at least 30 minutes before breakfast, and to avoid concurrent intake with calcium or iron supplements.
- Vitamin D supplementation at 2000 international units daily recommended, with advice to increase sunlight exposure as feasible.
- Ms. Parker has been informed that it may take 1-3 days to see effects of pharmacological treatment. If she sees an improvement she should continue treatment for a minimum of 4 weeks and up to 8 weeks to give their esophagus time to heal.
- If there are any signs of hypersensitivity reactions (such as hives, facial swelling, or breathing difficulties) stop treatment and seek urgent medical assistance.
Ms. Parker has been informed that they can fill their prescription at any pharmacy of their choosing.

MONITORING/FOLLOW UP:
- Ms. Parker is advised that if symptoms do not improve within 2-4 weeks she can book a follow up appointment and consider increasing the dosage of treatment.
- If she continues to have dyspepsia despite treatment, increased dosage, and lifestyle changes or she relapses after initial 8 week treatment trial, she may be referred to another healthcare professional.

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

Date:
2026-01-18