Date:
Patient:
MRN:
Clincian: (Endocrinologist)
Reason for Visit:
Follow-up for Hashimoto’s thyroiditis
Evaluation of symptoms and medication adherence
Review of laboratory results
Assessment of thyroid hormone levels and TSH response to treatment
History of Present Illness:
Briefly describe the patient’s current status:
Persistence or improvement of symptoms (fatigue, weight changes, mood changes)
Any new or worsening symptoms since last visit
Medication adherence and tolerability (levothyroxine dosage)
Past Medical History:
Date of Hashimoto’s thyroiditis diagnosis
Underlying medical conditions
Family History:
Family history of thyroid disorders
Social History:
Not typically relevant unless affecting overall health or medication adherence.
Physical Exam:
Vital Signs: May be abnormal with uncontrolled hypothyroidism (slow heart rate, low blood pressure).
Thyroid exam: Palpation for thyroid enlargement (goiter).
Labs:
Thyroid function tests (TFTs):
Free T4 (fT4) levels: Monitor for optimal replacement with levothyroxine.
Thyroid Stimulating Hormone (TSH) levels: Aim for TSH within the normal reference range.
Consider mentioning other labs ordered as needed (anti-thyroid peroxidase antibodies (TPOAb) and thyroglobulin antibodies (TgAb) – may be monitored for disease activity).
Assessment:
Summarize the disease status and treatment response:
Confirmation of Hashimoto’s thyroiditis diagnosis based on previous testing and ongoing presence of thyroid autoantibodies (if available).
Evaluate the effectiveness of levothyroxine therapy based on current symptoms and TSH level.
Consider mentioning if the TSH level is within the desired target range for optimal thyroid function.
Plan:
Outline the plan based on the assessment:
Medication adjustment: Adjust levothyroxine dosage as needed to optimize TSH levels and symptom control.
Repeat labs: Schedule follow-up blood tests to monitor thyroid function in a timeframe based on TSH stability.
Reiterate the importance of medication adherence for continued thyroid hormone replacement.
Education:
Document any education provided to the patient regarding:
The importance of taking levothyroxine medication as prescribed for optimal thyroid function.
The potential need for medication dosage adjustments based on ongoing monitoring.
The importance of recognizing and reporting any changes in symptoms that may indicate altered thyroid function.
Healthy lifestyle habits that can support overall well-being with Hashimoto’s thyroiditis (diet, exercise, stress management).
The availability of resources and support groups for patients with Hashimoto’s thyroiditis.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of their condition and treatment plan, and any concerns they may have about medication side effects, long-term management, or the impact of Hashimoto’s on their daily life.
Consider the potential impact of uncontrolled hypothyroidism on mental health and offer referral for mental health services if needed.
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.