Comprehensive Template for New Patients (Thyroidology) Template

Date: 01/11/2024
s10.ai is a 45-year-old male who presents for evaluation of:
CC: "I have been feeling extremely tired and gaining weight unexpectedly."
HPI: s10.ai reports experiencing fatigue and weight gain over the past six months. He has also noticed increased sensitivity to cold and dry skin. He has seen two physicians regarding these symptoms. s10.ai last felt well about a year ago, and the health change was triggered by a stressful work environment. He finds that rest slightly improves his fatigue, but stress worsens it.
Primary MD: Dr. Sarah Johnson  
Other Providers: Dr. Emily White (Endocrinologist)
Referred by: Dr. Michael Green
THREE WISHES for Health:  
1. To regain energy levels  
2. To lose the excess weight  
3. To manage stress effectively
PRESCRIPTIONS:  
Levothyroxine 50 mcg daily
SUPPLEMENTS:  
Vitamin D 1000 IU daily
ALLERGIES:  
None
CURRENT MEDICAL DIAGNOSES:  
Hypothyroidism
PAST MEDICAL HISTORY:  
Hypertension
SURGICAL HISTORY:  
Appendectomy in 2010
TRAUMA/INJURY HISTORY:  
None
OB/GYN HISTORY: N/A
HEALTH MAINTENANCE:  
Date of last Mammogram: N/A  
Date of last Pap Smear: N/A  
Date of last Colonoscopy: 01/06/2023  
Date of last Annual Physical Exam: 01/01/2024  
Date of last Bone Density Test/Dexa Scan: 01/07/2023  
Date of last Pelvic Ultrasound: N/A  
Date of last Prostate Exam: 01/08/2023
PERTINENT FAMILY HISTORY:  
Positive for:  
Mother - Hypothyroidism  
MGM - Diabetes  
MGF - Hypertension  
Father - None  
PGM - None  
PGF - None  
Uncle - None  
Aunt - None  
Siblings - None
THYROID FAMILY HISTORY:  
Mother has hypothyroidism
GYN FAMILY HISTORY:  
None known
SOCIAL HISTORY:  
Occupation: Accountant  
Domestic life/HOBBIES: Reading, hiking  
Toxic/hazardous exposures: None  
Alcohol: Occasionally  
Tobacco: Never  
Caffeine: 2 cups of coffee daily  
Other substances: None  
Activity and Exercise: Walks 30 minutes daily  
Nutrition and eating plan: Balanced diet, low in processed foods  
Weight currently: 85 kg, prior weight: 80 kg (6 months ago), weight goals: 80 kg
REVIEW OF SYSTEMS:  
GENERAL ROS:  
Allergy, ENT, Eyes, Ears, Throat, Chest/Lungs, Cardiovascular, Skin  
4- Dry skin  
3- Fatigue  
2- Cold intolerance  
1- Weight gain
Neuro/Psych:  
4- None  
3- None  
2- None  
1- Stress
GI, Urinary:  
4- None  
3- None  
2- None  
1- None
Musculoskeletal, Miscellaneous, Headaches, Fatigue:  
4- Fatigue  
3- Muscle aches  
2- None  
1- None
ROS Thyroid:  
4- Fatigue  
3- Weight gain  
2- Cold intolerance  
1- Dry skin
THYROID HISTORY:  
Diagnosed with hypothyroidism 6 months ago
ADRENAL HISTORY:  
No known adrenal issues  
Stress History summary: High stress due to work
ROS Adrenal:  
4- None  
3- None  
2- None  
1- Stress
ENERGY:  
Estimated avg. energy for past 3 months: 4  
Best time of day: Morning  
Worst time of day: Afternoon  
Physical activity – avg. time/day: 30 minutes  
Type of activity: Walking
SLEEP:  
Average  hours/day: 7  
Time in bed: 10 PM  
SOL time: 30 minutes  
 Awakenings/night: 2  
Reason: Stress  
Time of arising: 6 AM  
Naps: Occasionally  
How much Caffeine and what kind: 2 cups of coffee
GLUCOSE/INSULIN:  
No concerns  
Food History: Balanced diet, adheres 90% of the time
ROS Glucose/Insulin:  
4- None  
3- None  
2- None  
1- None
PHYSICAL EXAM:  
Height: 175 cm  
Current Weight: 85 kg  
BMI: 27.8  
BP: 130/85
Demeanor: Alert and cooperative  
Head: Normocephalic  
Face: No abnormalities  
Neck: Thyroid slightly enlarged  
Lungs: Clear  
Skin: Dry  
Habitus: Overweight
REVIEW OF RECORDS - notable issues:  
Past medical history of hypertension
ASSESSMENT/PLAN:  
Assessment: Hypothyroidism, stress-related fatigue  
Plans: Continue Levothyroxine, implement stress management techniques, follow up in 3 months