St. Josephs-Follow up

Informed verbal consent was obtained from this patient to communicate and provide care using virtual and other telecommunications tools. This patient has been explained the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. We have discussed that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and patient understands the need to seek urgent care in an Emergency Department as necessary.

Subjective:
PATIENT IDENTIFICATION:
The patient is Ms. Smith. No date of birth, gender, or identification numbers were provided in the encounter documentation.

REASON FOR REASSESSMENT:
- Persistent fatigue x3mo
- Wt gain, irregular menses, AM joint stiffness
- Hx maternal Hashimoto's
- Labs: ↑TSH, low-normal free T4, +anti-TPO, mild Vit D deficiency

Objective:
PATIENT STATUS:
- Fatigue persists, wt gain, irregular menses
- AM joint stiffness
- Hair thinning, constipation, cold intolerance present
- Labs: TSH 7.8, free T4 low-normal, anti-TPO +, Vit D mild deficiency

Assessment:
ASSESSMENT:
- Hypothyroidism, likely autoimmune (Hashimoto's): fatigue, weight gain, irregular menses, morning joint stiffness, hair thinning, constipation, cold intolerance; labs: TSH 7.8, low-normal free T4, positive anti-TPO antibodies; maternal hx Hashimoto's
- Vitamin D deficiency: mild
- No mention of hair thinning, constipation, or feeling unusually cold being absent

Plan:
PLAN:
1. Hypothyroidism (E03.9):
• Tx: Levothyroxine 50 mcg qd
• F/u: TSH, free T4 in 6 wks
• Refer: Rheum if joint sx persist
• Tests: None
2. Vitamin D deficiency (E55.9):
• Tx: Vitamin D 2000 IU qd
• F/u: 3 mo Vit D
• Refer: None
• Tests: None
- Counsel: Balanced diet, light exercise, avoid Ca/Fe with thyroid med, take on empty stomach