Pharmacy - Oral Thrush

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

GENERAL:
PharmaNet has been checked. 

Objective:
REASON FOR VISIT:
Persistent fatigue.

ASSESSMENT:
Ms. Taylor reports persistent fatigue for approximately three months. She describes associated symptoms including weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and increased sensitivity to cold. There are no alleviating or exacerbating factors mentioned. She has not reported any over-the-counter treatments or home remedies. Family history is notable for Hashimoto’s thyroiditis in her mother. 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.

Subjective:
PAST MEDICAL HISTORY:
No significant findings.

CURRENT MEDICATIONS:
No current medications reported prior to this visit.

ALLERGIES:
No allergies reported.

Assessment:
DIAGNOSIS:
E03.9

Plan:
PLAN:
- Ms. Taylor is educated regarding the diagnosis of autoimmune hypothyroidism and mild vitamin D deficiency. She is instructed on the importance of medication adherence and timing of levothyroxine administration, specifically to take it on an empty stomach and to avoid concurrent intake with calcium or iron supplements. She is advised to maintain a balanced diet and engage in regular light physical activity. Sunlight exposure is recommended to address vitamin D deficiency.
- Treatment: Levothyroxine 50 micrograms orally once daily, to be taken 30 minutes before breakfast. Vitamin D supplementation at 2000 international units daily. Prescriptions are sent electronically.

MONITORING/FOLLOW UP:
- Follow up in six weeks for repeat thyroid function testing and assessment of response to levothyroxine therapy.
- Ms. Taylor is advised to contact her healthcare provider if symptoms persist or worsen.

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

DATE:
2026-02-03