Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint: This section will vary depending on the severity of hypothyroidism and the duration of treatment. Symptoms may include:
Fatigue (most common symptom)
Weight gain (unexplained)
Cold intolerance
Dry skin and hair
Constipation
Muscle weakness
Hoarseness
Difficulty concentrating
Depression (in some cases)
Irregular menstrual periods (in women)
Edema (fluid retention) – in severe cases
现病史 (xiàn bìng shǐ) History of Present Illness:
Age at diagnosis of hypothyroidism
Duration of symptoms
Severity of symptoms (based on clinical presentation)
Changes in symptoms since starting treatment (if applicable)
Current dose and type of thyroid medication
既往史 (jì wàng shǐ) Past Medical History:
Underlying cause of hypothyroidism (e.g., Hashimoto’s thyroiditis, post-ablative therapy, medication-induced)
Prior surgeries or procedures (e.g., thyroidectomy, radiation therapy)
History of other autoimmune diseases
家族史 (jiā zú shǐ) Family History:
Family history of thyroid disease (especially Hashimoto’s thyroiditis)
社会史 (shè huì shǐ) Social History:
Diet (potential for nutritional deficiencies)
Stress levels (can worsen symptoms)
Smoking history (can interfere with thyroid hormone absorption)
查体 (chá tǐ) Physical Examination:
Vital signs (may be normal or show slow heart rate and low blood pressure)
General appearance (dry skin, lethargy, puffiness)
Skin exam (dryness, hair loss)
Neurological exam (assessing for reflexes, memory)
Cardiovascular exam (assessing heart rate and rhythm)
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Thyroid function tests (TFTs):
Thyroid Stimulating Hormone (TSH) – primary test to diagnose and monitor hypothyroidism
Free thyroxine (fT4) – may be low in hypothyroidism
Thyroid peroxidase antibodies (TPOAb) and Thyroglobulin antibodies (TgAb) – helpful in identifying the cause of hypothyroidism (Hashimoto’s thyroiditis)
Lipid panel – may show elevated cholesterol levels in hypothyroidism
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies are not routinely used for diagnosing hypothyroidism. Ultrasound of the thyroid gland may be considered if a nodule is suspected.
诊断 (zhěn duàn) Diagnosis:
Hypothyroidism (confirmed by TSH and fT4 levels)
Underlying cause of hypothyroidism (if identified)
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Levothyroxine (synthetic thyroid hormone) replacement therapy – the mainstay of treatment
Dosage adjustments based on follow-up TSH levels
Monitoring for medication adherence
预后 (yù hòu) Prognosis:
Discuss the outlook based on the underlying cause, adherence to treatment, and response to medication.
With proper treatment, most people with hypothyroidism can live normal, healthy lives.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of taking medication as prescribed and at the appropriate time
Importance of regular follow-up appointments and blood tests to monitor TSH levels
Importance of a healthy diet
Recognizing symptoms of under- or over-treatment
Importance of discussing any new medications with a doctor (potential interactions with thyroid medication)
下次随访 (xià cì suí fǎng) Next Follow-up:
Schedule for the next appointment depends on the initial TSH level and response to treatment.
Regular follow-up is essential to monitor TSH levels and adjust medication dosage as needed.