SOAP / Chart / Progress Notes
Sample Name: Acquired Hypothyroidism Followup
Description: Return visit to the endocrine clinic for acquired hypothyroidism, papillary carcinoma of the thyroid gland status post total thyroidectomy in 1992, and diabetes mellitus.
(Medical Transcription Sample Report)
1. Acquired hypothyroidism.
2. Papillary carcinoma of the thyroid gland, status post total thyroidectomy in 1992.
3. Diabetes mellitus.
4. Insomnia with sleep apnea.
HISTORY OF PRESENT ILLNESS: This is a return visit to the endocrine clinic for the patient with history as noted above. She is 45 years old. Her last visit was about 6 months ago. Since that time, the patient states her health has remained unchanged. Currently, primary complaint is one of fatigue that she feels throughout the day. She states, however, she is doing well with CPAP and wakes up feeling refreshed but tends to tire out later in the day. In terms of her thyroid issues, the patient states that she is not having signs or symptoms of thyroid excess or hypothyroidism. She is not reporting temperature intolerance, palpitations, muscle weakness, tremors, nausea, vomiting, constipation, hyperdefecation or diarrhea. Her weight has been stable. She is not reporting proximal muscle weakness.
1. Levothyroxine 125 micrograms p.o. once daily.
6. Byetta injected twice daily.
REVIEW OF SYSTEMS: As stated in the HPI. She is not reporting polyuria, polydipsia or polyphagia. She is not reporting fevers, chills, sweats, visual acuity changes, nausea, vomiting, constipation or diarrhea. She is not having any lightheadedness, weakness, chest pain, shortness of breath, difficulty breathing, orthopnea or dyspnea on exertion.
GENERAL: She is an overweight, very pleasant woman, in no acute distress. VITAL SIGNS: Temperature 96.9, pulse 85, respirations not counted, blood pressure 135/65, and weight 85.7 kg. NECK: Reveals well healed surgical scar in the anteroinferior aspect of the neck. There is no palpable thyroid tissue noted on this examination today. There is no lymphadenopathy. THORAX: Reveals lungs that are clear, PA and lateral, without adventitious sounds. CARDIOVASCULAR: Demonstrated regular rate and rhythm. S1 and S2 without murmur. No S3, no S4 is auscultated. EXTREMITIES: Deep tendon reflexes 2+/4 without a delayed relaxation phase. No fine resting tremor of the outstretched upper extremity. SKIN, HAIR, AND NAILS: All are unremarkable.
LABORATORY DATABASE: Lab data on 08/29/07 showed the following: Thyroglobulin quantitative less than 0.5 and thyroglobulin antibody less than 20, free T4 1.35, and TSH suppressed at 0.121.
ASSESSMENT AND PLAN:
This is a 45-year-old woman with history as noted above.
1. Acquired hypothyroidism, status post total thyroidectomy for papillary carcinoma in 1992.
2. Plan to continue following thyroglobulin levels.
3. Plan to obtain a free T4, TSH, and thyroglobulin levels today.
4. Have the patient call the clinic next week for followup and continued management of her hypothyroid state.
5. Plan today is to repeat her thyroid function studies. This case was discussed with Dr. X and the recommendation. We are giving the patient today is for us to taper her medication to get her TSH somewhere between 0.41 or less. Therefore, labs have been drawn. We plan to see the patient back in approximately 6 months or sooner. A repeat body scan will not been done, the one in 03/06 was negative.
Keywords: soap / chart / progress notes, thyroid function studies, thyroid gland, diabetes mellitus, papillary carcinoma, total thyroidectomy, acquired hypothyroidism, carcinoma, thyroidectomy, thyroglobulin, hypothyroidism,