Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for central hypothyroidism or evaluation of new symptoms.
SOAP
Subjective (S):
Symptoms:
Inquire about symptoms suggestive of hypothyroidism, such as:
Fatigue and lethargy
Weight gain (may not be present in all cases)
Cold intolerance
Dry skin and hair
Constipation
Muscle aches and stiffness
Depression or mood changes
Difficulty concentrating
Slowed thinking
Hoarseness (less common)
Menstrual irregularities (females)
Decreased libido
Hair loss (may be subtle)
Treatment History:
Note the type and dosage of thyroid replacement medication the patient is currently taking.
Explore for any medication adherence issues.
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying cause of central hypothyroidism (e.g., pituitary tumor, Sheehan’s syndrome, hypothalamic injury)
Comorbidities like diabetes mellitus, heart disease, or depression
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Assess for bradycardia (slow heart rate) which can be a sign of hypothyroidism.
Physical Exam:
Briefly document:
Skin texture (dryness)
Hair quality (coarse, brittle)
Presence of edema (fluid retention – uncommon)
Deep tendon reflexes (may be slowed)
Mental status (depression, slow speech)
Signs of weight gain (if present)
Assessment (A):
Thyroid Function Tests:
Review recent thyroid function tests, including:
Thyroid-stimulating hormone (TSH) level (elevated in central hypothyroidism)
Free thyroxine (fT4) level (may be low or within normal range)
Clinical Response:
Assess the patient’s response to treatment based on:
Improvement in symptoms of hypothyroidism
Overall well-being and energy levels
Etiology (Cause):
Based on history and investigations, confirm or re-evaluate the underlying cause of central hypothyroidism.
Plan (P):
Medication Adjustments (if needed):
Based on TSH and clinical response, adjust the thyroid replacement medication dosage to achieve optimal thyroid hormone levels and symptom control.
Laboratory Monitoring:
Schedule follow-up thyroid function tests at appropriate intervals to monitor response to treatment.
Management of Underlying Cause (if possible):
If a specific cause of central hypothyroidism is identified, consider treatment options to address it (e.g., pituitary tumor surgery).
Patient Education:
Reinforce the importance of:
Taking thyroid replacement medication as prescribed.
Recognizing symptoms of under- or over-treatment.
The importance of regular follow-up appointments.
Follow-up:
Schedule follow-up visits based on the need for medication adjustments and monitoring.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., endocrinologist)
Addressing potential complications of untreated central hypothyroidism (e.g., heart disease, infertility)
Importance of managing other medical conditions that might contribute to symptoms (e.g., depression)
Discussing potential side effects of thyroid replacement medication
Exploring the impact of central hypothyroidism on quality of life