Scribe BC - BG New Consult

Scribe BC - BG New Consult **REASON FOR CONSULTATION:** The patient, [insert age] year old female, is referred for evaluation of new-onset fatigue, weight gain, and irregular menstrual cycles. These symptoms began approximately 3 months ago and have progressively worsened. She reports feeling tired most days, despite getting adequate sleep. She has gained 10 pounds without any changes to her diet or exercise routine. Her menstrual cycles have become irregular, with periods occurring every 2-3 months. **HISTORY OF PRESENT ILLNESS:** The patient reports a gradual onset of fatigue, starting with mild tiredness that has escalated to significant fatigue, impacting her daily activities. She denies any recent illnesses or infections. The weight gain has been primarily in the abdominal area. She denies any changes in appetite. The irregular menstrual cycles are associated with heavier bleeding and increased cramping. She has not sought any prior medical care for these symptoms. **REVIEW OF SYSTEMS:** * **General:** Reports fatigue, weight gain. * **Endocrine:** Reports irregular menstrual cycles. * **Gastrointestinal:** Denies nausea, vomiting, or abdominal pain. * **Musculoskeletal:** Denies muscle weakness or joint pain. * **Neurological:** Denies headaches, dizziness, or vision changes. **PAST MEDICAL HISTORY:** The patient has a history of seasonal allergies, treated with over-the-counter antihistamines. No prior hospitalizations or surgeries. **MEDICATIONS:** * Loratadine 10mg daily, as needed for allergies. **ALLERGIES:** * No known drug allergies. **FAMILY HISTORY:** * Mother: Type 2 diabetes. * Father: Hypertension. * Sister: Healthy. **SOCIAL HISTORY:** The patient is a non-smoker and drinks alcohol occasionally. She works as a teacher and reports a moderate level of stress. She exercises 3 times per week. **PHYSICAL EXAMINATION:** * **General:** Appears well-nourished, but slightly overweight. * **Vital Signs:** Blood pressure 130/80 mmHg, heart rate 78 bpm, respiratory rate 16 breaths/min, temperature 37°C. * **Thyroid:** Palpable, no nodules or enlargement. **INVESTIGATIONS:** * Complete blood count (CBC) - 1 November 2024 * Comprehensive metabolic panel (CMP) - 1 November 2024 * Thyroid-stimulating hormone (TSH) - 1 November 2024 * Free T4 - 1 November 2024 * Fasting blood glucose - 1 November 2024 **IMPRESSION:** * Possible hypothyroidism, based on symptoms of fatigue, weight gain, and irregular menses. Differential diagnoses include polycystic ovary syndrome (PCOS) and early menopause. **PLAN:** * Order TSH and free T4 to assess thyroid function. * Order fasting blood glucose to rule out diabetes. * Discuss lifestyle modifications, including diet and exercise. * Schedule a follow-up appointment in 4 weeks to review lab results and discuss further management. **FOLLOW-UP:** * Follow-up appointment in 4 weeks. "This document was created using AI Ambient Scribe and Front-End Speech Recognition software and may include incorrect spelling/words. Consent for usage of AI was obtained by patient/guardian."