New Patient Comprehensive template (for Thyroidologists)

Date: 01/11/2024 John Doe is a 45-year-old male who presents for evaluation of: CC: "I have been feeling extremely tired and gaining weight unexpectedly." HPI: John 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. John 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