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)
Subjective:
[Detailed history of the presenting complaint(s), including onset, duration, severity, aggravating or alleviating factors, associated symptoms, previous treatments and responses, and owner/patient-reported concerns] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences, using the patient as the subject, e.g., "I reviewed Mr/Mrs [X]. He/She has...".)
Objective:
[Vital signs including weight, blood pressure, and other relevant parameters] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences.)
[Physical examination findings with emphasis on endocrine examination: thyroid exam, skin markers, secondary sexual characteristics, growth parameters in children, etc.] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences.)
[Investigation results including laboratory tests, imaging studies, or other diagnostics] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences.)
Patient Education:
[Education provided on the diagnosed condition including its nature, impact on health, complications, and importance of treatment adherence. Include any medication changes, new medications, or medications advised to stop if explicitly mentioned.] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences, from clinician’s perspective, e.g., "I explained to him/her that...".)
[Instructions for monitoring and managing symptoms, such as glucose monitoring for diabetes, or weight/temperature monitoring for thyroid conditions] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences.)
[Concerns raised by patient or family during consultation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences.)
Plan:
[Planned follow-up arrangements including timing (weeks/months), location, or further investigations] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as narrative in full sentences, e.g., "I plan to review Mr/Mrs [X] in...".)
Medical History:
[List medical diagnoses mentioned during consultation] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as list.)
Medication List:
[List medications and doses mentioned during consultation, including new medications and changes to existing medications] (Only include if explicitly mentioned in transcript, context or clinical note; else omit completely. Write as list.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference. If information has not been explicitly mentioned, omit it completely. Write in paragraphs of full sentences unless otherwise specified.)