Urology Inpatient Progress Note

Date of Service: 2026-02-09
Patient: Ms. Carter

SYNOPSIS: 
This is a female with a history of autoimmune thyroiditis and vitamin D deficiency.

INTERVAL HISTORY:
Ms. Carter reports persistent fatigue for the past three months, with associated weight gain, irregular menstrual cycles, morning joint stiffness, hair thinning, constipation, and feeling unusually cold.

SUBJECTIVE:
"I’ve been having persistent fatigue over the last few months. It’s been affecting my ability to work and take care of my kids."

OBJECTIVE:

LABS, IMAGING, AND OTHER STUDIES:
- Laboratory: Laboratory results indicate an elevated thyroid-stimulating hormone (TSH) level of 7.8, a low-normal free T4 level, and positive anti-thyroid peroxidase (anti-TPO) antibodies. Additionally, a Vitamin D panel revealed mild deficiency.

ASSESSMENT/PLAN:
Ms. Carter is a female patient.

1. Autoimmune thyroiditis (ICD-10: E06.3)
- Plan: Prescribed levothyroxine 50 mcg daily to manage hypothyroidism, with instructions to take it on an empty stomach, ideally 30 minutes before breakfast. Advised rechecking thyroid function tests, including TSH and free T4, in six weeks to evaluate the response and adjust the dosage if needed.
- Counseling: Discussed the potential connection between joint stiffness and hypothyroidism, with a plan to monitor these symptoms closely. If the stiffness persists, a referral to a rheumatologist will be considered. Provided dietary and lifestyle guidance, emphasizing the importance of a balanced diet and regular light physical activity. Specifically instructed the patient to avoid taking thyroid medication simultaneously with calcium or iron supplements, as this may interfere with absorption.
2. Vitamin D deficiency, unspecified (ICD-10: E55.9)
- Plan: Recommended Vitamin D supplementation at 2000 IU daily and suggested rechecking Vitamin D levels in three months. Encouraged regular sunlight exposure to naturally improve Vitamin D levels.

ORDERS:
- Recheck thyroid function tests (TSH, free T4) in six weeks.
- Recheck Vitamin D level in three months.