PHC-General Surgery Consult CHR

regarding autoimmune thyroiditis. The patient has experienced persistent fatigue over the past three months, with associated symptoms including weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and feeling unusually cold. Laboratory evaluation revealed an elevated TSH level of 7.8, low-normal free T4, and positive anti-TPO antibodies. A mild Vitamin D deficiency was also identified. Levothyroxine 50 mcg daily was initiated, with instructions regarding administration and follow-up thyroid function testing in six weeks. Vitamin D supplementation at 2000 IU daily was recommended, with re-evaluation in three months. The patient was advised on dietary measures and regular light physical activity.

**Family History:** The patient's mother has a history of Hashimoto's thyroiditis.

**Past Medical History:** 

**Past Surgical History:** 

**Medications:** None.

**Allergies:** 

**Social History:** 

On examination today, Examination of the abdomen shows a soft, non-distended, and non-tender abdomen. There is no surgical scar.

**Impression:** Autoimmune thyroiditis with associated hypothyroidism and mild Vitamin D deficiency.

Thank you for involving us in the care of this patient.

Best regards,

Jamie Lee, General Surgery

(This note was generated with the assistance of automated AI Scribe software designed to support the documentation process. Information about AI Scribe is available to the patient to review. The patient provided informed verbal consent to use the AI scribe during this visit.)