Question:  Allergies: Chief complaint: Past medical history: Family history: Home medication and dose: Route: Frequency: Last dose (date/time)

Patient Presentation:

Monica Buffay is a 35-year-old woman who presents to her new PCP with some complaints of feeling tired, lethargic, and “fuzzy-headed” for the last 6 months. When asked about how she has been feeling she uttered “I always feel so tired lately. Maybe I’m working too hard?” . She has seen her previous PCP several times over this period of time, and she has been told that her symptoms are probably due to anemia, depression, or perimenopause. Several months ago, she developed menorrhagia that resulted in iron deficiency anemia (hematocrit 31%, MCV 68 μm3). However despite treatment with iron (and resultant improvement of her anemia), a hormonal contraceptive to help regulate her menstrual cycle, and an antidepressant, her symptoms have slowly worsened. She notes that 24 months ago, she attended a local health fair that provided a variety of laboratory tests. The result of her TSH at that time was 6.2 mIU/L, and her total cholesterol was 246 mg/dL. Her PCP felt that the TSH value was compatible with subclinical hypothyroidism and therefore could not explain her symptoms. She also has noticed that her skin seems more dry and itchy and that she has difficulty keeping warm and frequently wears a sweater, even in warm weather. When asked about her family background, it was found that her father was Positive for CVD, CAD; had Type 2 DM and died of CVA at age 55, her mother is alive with Type 2 DM, HTN, and hypothyroidism and had an MI at 60; she has one brother with Type 2 DM and a sister with HTN.

Her medications were listed as follows:

• MOM 30 mL po daily PRN constipation
• Fluoxetine 20 mg po daily
• Ortho Tri-Cyclen-28 1 po daily
• FeSO4 300 mg po daily
• Calcium carbonate 500 mg po twice daily
• Acetaminophen 325–650 mg po PRN headache, body aches

Review of Systems:

Occasional headaches relieved with non-aspirin pain reliever; (–) tinnitus, vertigo, or infections; frequent body aches which she attributes to lack of exercise; (–) change in urinary frequency, but she has noticed an increase in the number of episodes of constipation in the past year; reports cold extremities; (–) history of seizures, syncope, or LOC, (+) dry skin

Physical Examination

Gen

Well-appearing, middle-aged, Hispanic woman in NAD

VS

BP 142/89, P 64, RR 18, T 36.4°C; Wt 68 kg, Ht 5'4''

Skin

Dry appearing skin and scalp; (–) rashes or lesions

HEENT

PERRLA, EOMI; trace periorbital edema; (–) sinus tenderness; TMs appear normal

Neck/Lymph Nodes

(–) thyroid nodules or goiter; (–) lymphadenopathy, (–) carotid bruits

Lungs/Thorax

CTA

Breasts

(–) lumps/masses

CV

RRR, normal S1, S2; (–) S3 or S4

Abd

NT/ND, (–) organomegaly

Neuro

A & O × 3; CN II–XII intact; DTRs 2+, symmetric

Labs

Assessment

35-year-old woman with signs, symptoms, and laboratory tests consistent with hypothyroidism. 

Question:

1.  Allergies:
2. Chief complaint:
3. Past medical history:
4. Family history:

5. Home medication and dose:
   Route:	Frequency:	Last dose (date/time):