Hypothyroid Case Study
CC
Sophia is a 25-year-old female here today to discuss her thyroid.
HPI
The patient in the past has been diagnosed with hypothyroidism. She was diagnosed in 2011 and took prescription levothyroxine for approximately three months and then was told that she could stop it upon the recommendation of her physician. Since then, she has not been on any medication. She did recently do laboratory studies for me today, which she is here to discuss. They do show an elevated TSH of 5.01. She wanted to talk about medication therapy before starting it. She does admit to some fatigue, intermittently. She says she has myalgias on and off. Sometimes feels a little bit shaky and dizzy as well. She is not sure if that is related to her thyroid or not. She has not had any unusual rashes. There has been no blurred or double vision. No headaches. No feeling of off balance per se. Occasionally will have dizziness. She occasionally will have the feeling of palpitations but no specific chest pain, shortness of breath, dyspnea on exertion. . She has not had any weight gain without trying, in fact, she is losing weight. She as lost a couple of pounds when she has been trying to gain weight. She off and on will have issues with constipation and that is not a predominant …show more content…
Allergies
No known drug allergies.
Social History
Lifetime nonsmoker.
O
Vital Signs
Temperature: 97.8. BP: 118/60. HR: 76. R: 14. W: 113.
General
A well-developed, well-nourished female no acute distress seated comfortably in the exam room. She has good eye contact. Answers questions appropriately. Alert and oriented. Very pleasant.
Neck
Supple. No bruits or JVD. No masses or tenderness.
Heart
Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.
Lungs
Clear bilaterally. Good breath sounds. No wheeze, no rhonchi.
Abdomen
Soft, nontender. No masses or discomfort.
Skin
Good turgor. Less than 2 second capillary
Sophia is a 25-year-old female here today to discuss her thyroid.
HPI
The patient in the past has been diagnosed with hypothyroidism. She was diagnosed in 2011 and took prescription levothyroxine for approximately three months and then was told that she could stop it upon the recommendation of her physician. Since then, she has not been on any medication. She did recently do laboratory studies for me today, which she is here to discuss. They do show an elevated TSH of 5.01. She wanted to talk about medication therapy before starting it. She does admit to some fatigue, intermittently. She says she has myalgias on and off. Sometimes feels a little bit shaky and dizzy as well. She is not sure if that is related to her thyroid or not. She has not had any unusual rashes. There has been no blurred or double vision. No headaches. No feeling of off balance per se. Occasionally will have dizziness. She occasionally will have the feeling of palpitations but no specific chest pain, shortness of breath, dyspnea on exertion. . She has not had any weight gain without trying, in fact, she is losing weight. She as lost a couple of pounds when she has been trying to gain weight. She off and on will have issues with constipation and that is not a predominant …show more content…
Allergies
No known drug allergies.
Social History
Lifetime nonsmoker.
O
Vital Signs
Temperature: 97.8. BP: 118/60. HR: 76. R: 14. W: 113.
General
A well-developed, well-nourished female no acute distress seated comfortably in the exam room. She has good eye contact. Answers questions appropriately. Alert and oriented. Very pleasant.
Neck
Supple. No bruits or JVD. No masses or tenderness.
Heart
Regular rate and rhythm. Normal S1, S2. No murmurs, rubs, or gallops.
Lungs
Clear bilaterally. Good breath sounds. No wheeze, no rhonchi.
Abdomen
Soft, nontender. No masses or discomfort.
Skin
Good turgor. Less than 2 second capillary