Hypothyroidism

HISTORY:

‍FatigueUnintended weight gain for ‍ ‍hoursdays

‍fatigue

‍increase in weight

‍dry skin

‍cold intolerance

‍constipation

‍depressed mood

‍hair loss

‍muscle aches

‍menorrhagia

‍dry skin

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Eyes: -R: ‍normal, -L: ‍normal, ‍

Throat: ‍normalrednessexudate

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍

Musculoskeletal: joints ‍ ‍normal, ‍no limited ROM

Neurologic: cranial nerves ‍normal, strength ‍5/5 throughout, sensation ‍normal, reflexes ‍2+ throughout, cerebellar function ‍normal, gait ‍stable

Mental status: ‍alert, ‍oriented, speech ‍clear, mood ‍normal, thought process ‍organized, ‍no suicidal ideation, judgment ‍good



ASSESSMENT:

‍Hypothyroidism ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍TSH, ‍free T4, ‍free T3, ‍thyroid antibodies

- Thyroid ultrasound

- ‍Levothyroxine

- Repeat TSH in ‍ ‍weeksmonths

- Referral to endocrinologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if side effects develop