Letter to GP by DrZeminCao

Subjective: Mrs. Evelyn Hayes, [age 62], presented today with a three-month history of fatigue, weight gain, and increased sensitivity to cold. She reports that these symptoms have gradually worsened, impacting her daily activities. She denies any chest pain, shortness of breath, or palpitations. She has not had any previous treatments for these symptoms. Objective: Her weight is 78 kg, blood pressure is 130/80 mmHg, and pulse is 72 bpm. Physical examination revealed a slightly enlarged thyroid gland, no skin markers, and normal secondary sexual characteristics. Investigation results showed a TSH level of 12 mIU/L (elevated) and a free T4 level of 8 pmol/L (low). Patient Education: I explained to Mrs. Hayes that her symptoms and test results are consistent with hypothyroidism. I discussed the nature of the condition, its impact on her health, and the importance of treatment adherence. I informed her that she will be starting levothyroxine 50 mcg daily. I also advised her to monitor her weight and temperature. Plan: I plan to review Mrs. Hayes in six weeks to assess her response to levothyroxine and repeat thyroid function tests. Medical History: Hypothyroidism Medication List: Levothyroxine 50 mcg daily (new medication)