Date:
Patient:
MRN:
Clincian: (Endocrinologist)
Reason for Visit:
Follow-up for Graves’ disease
Evaluation of thyroid function and clinical symptoms
Review of laboratory and imaging results (if applicable)
Discussion of treatment plan and potential side effects
History of Present Illness:
Briefly describe the patient’s current status:
Duration of symptoms (heat intolerance, weight loss despite normal appetite, anxiety, palpitations, tremor, fatigue)
Severity and characteristics of symptoms
Response to previous treatment approaches (antithyroid medications, radioactive iodine ablation, surgery)
Past Medical History:
Underlying medical conditions (thyroid eye disease, Graves’ dermopathy)
Family history of thyroid disorders
Social History:
Not typically relevant unless affecting overall health or medication adherence.
Physical Exam:
Vital Signs: May be abnormal depending on the severity of hyperthyroidism (tachycardia, hypertension).
Thyroid exam: Gland may be enlarged (goiter) and hyperactive.
Look for signs of Graves’ ophthalmopathy (eyelid retraction, proptosis – bulging eyes).
Assess for signs of pretibial myxedema (thickening and reddening of the skin on the shins).
Labs:
Thyroid function tests (TFTs):
Free T4 (fT4) levels will be elevated.
Thyroid Stimulating Hormone (TSH) levels are typically suppressed.
Consider mentioning other labs ordered as needed (anti-thyroid peroxidase antibodies (anti-TPO) and thyroglobulin antibodies to differentiate Graves’ disease from other causes of hyperthyroidism).
Imaging:
Thyroid ultrasound: May be used to assess the size and structure of the thyroid gland and identify any nodules.
Imaging of the eyes (orbital CT scan) may be ordered in some cases to evaluate Graves’ ophthalmopathy.
Assessment:
Summarize the diagnosis and disease activity:
Confirmation of Graves’ disease diagnosis based on clinical presentation, laboratory findings (elevated fT4, suppressed TSH), and positive anti-thyroid antibodies (if available).
Severity of hyperthyroidism based on TFT results and symptoms.
Plan:
Outline the treatment plan based on the assessment:
Antithyroid medications: Methimazole or propylthiouracil are used to block the production of thyroid hormones.
Radioactive iodine ablation: A radioactive isotope of iodine is used to destroy thyroid tissue and reduce hormone production.
Surgery (thyroidectomy): May be considered in some cases, such as large goiter, severe hyperthyroidism, or intolerance to other treatment options.
Beta-blockers: May be used to control symptoms like tremors and heart palpitations while definitive treatment takes effect.
Prognosis:
Briefly discuss the prognosis. Graves’ disease can be a lifelong condition, but with proper treatment, most patients can achieve normal thyroid function and control their symptoms.
Emphasize the importance of ongoing monitoring with regular lab tests and follow-up appointments to ensure optimal treatment and prevent complications.
Education:
Document any education provided to the patient regarding:
The nature of Graves’ disease, its symptoms, and potential complications
The details of the prescribed treatment plan and potential side effects
The importance of medication adherence and regular follow-up appointments
Warning signs and symptoms of uncontrolled hyperthyroidism or treatment side effects
The potential need for long-term management and monitoring
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about medication side effects, long-term management, or the impact of Graves’ disease on daily activities.
Consider mentioning the potential risks of radioactive iodine ablation, particularly for women who are pregnant or breastfeeding.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with an endocrinologist for diagnosis, treatment recommendations, and prognosis.