Patient: [Patient Name]
Date: [Date of Encounter]
I. Diagnosis:
Age at diagnosis of congenital hypothyroidism
II. Current Medications:
Thyroid hormone replacement therapy (type, dose, route)
III. History of Present Illness:
Reason for this visit (routine follow-up, medication adjustment)
Current symptoms (if any): Assess for potential signs and symptoms of under- or over-treatment with thyroid medication.
Under-treatment (fatigue, constipation, cold intolerance, weight gain, dry skin, hair loss)
Over-treatment (irritability, anxiety, tremors, heat intolerance, diarrhea, weight loss)
Developmental milestones (meeting age-appropriate milestones)
Growth parameters (weight, height, head circumference)
IV. Past Medical History:
Screening method used for diagnosis (newborn screening)
Initial TSH and T4 levels at diagnosis
Past hospitalizations (related to hypothyroidism)
V. Social History:
Medication adherence
Dietary habits
VI. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
General appearance (growth, alertness)
Neurologic exam (muscle tone, reflexes)
Skin examination (dryness)
VII. Laboratory Studies:
Thyroid function tests (TSH, free T4) – primary monitoring tests
Other tests (TSH receptor antibodies) – if indicated
VIII. Assessment:
Current thyroid hormone replacement therapy adequacy (based on symptoms, physical exam, and labs)
Growth and development (on track or delayed)
Risk of complications (developmental delays, goiter)
IX. Plan:
Medication adjustments (dose changes) based on TSH and T4 levels and clinical assessment.
Follow-up laboratory testing schedule (frequency depends on age and stability)
Education:
Importance of medication adherence and avoiding missed doses.
Recognizing signs and symptoms of under- or over-treatment.
Importance of regular follow-up.
Referral (if indicated):
Pediatric endocrinologist for complex cases or concerns about growth/development.
X. Notes:
Include any additional observations or concerns, such as patient’s understanding of the condition, adherence to recommendations, and social support system.
XI. Resources:
Consider providing patient education materials on congenital hypothyroidism from reputable sources (e.g., American Thyroid Association, National Endocrine Society).