Date:
Patient:
Reason for Visit: Follow-up for subclinical hypothyroidism
History of Present Illness:
Date of initial diagnosis of subclinical hypothyroidism
Presence of any symptoms suggestive of hypothyroidism (fatigue, weight gain, cold intolerance, constipation, hair loss, dry skin, irregular periods) – even if mild
Review of past thyroid function tests (TFTs) with specific values (TSH, fT4)
Past Medical History:
Autoimmune diseases (Hashimoto’s thyroiditis is a common cause)
Family history of thyroid disease
Prior surgeries or radiation treatments involving the thyroid gland
Use of medications that can affect thyroid function (e.g., amiodarone, lithium)
Social History:
Current medications and supplements
Dietary habits
Physical Exam:
Vital signs (including heart rate, which may be slow in hypothyroidism)
Skin assessment (dryness, texture)
Neurological exam (assessing reflexes, which may be slowed in hypothyroidism)
Labs:
Current TSH and fT4 levels
Consideration of anti-TPO antibodies (if Hashimoto’s thyroiditis is suspected)
Diagnosis:
Subclinical hypothyroidism (mention current TSH level)
Management:
Discuss the decision regarding treatment initiation based on TSH level, presence of symptoms, and patient preferences.
If treatment is initiated:
Specify the medication (levothyroxine) and dosage.
Explain the importance of taking medication on an empty stomach and avoiding certain foods/supplements that can interfere with absorption.
Plan:
Outline the plan for follow-up:
Schedule for repeat TSH and fT4 testing (frequency depends on initial TSH level and treatment decision)
Discuss potential need for adjustments in medication dosage based on lab results
Re-evaluation for symptoms of hypothyroidism
Education:
Educate the patient about subclinical hypothyroidism, including the potential benefits and risks of treatment.
Provide information on healthy lifestyle choices that can support thyroid function (e.g., balanced diet, regular exercise).
Prognosis:
Subclinical hypothyroidism can progress to overt hypothyroidism. Early diagnosis and appropriate treatment can help prevent complications.
Additional Information:
Document any previous discussions about the risks and benefits of monitoring vs. treatment.
Note any patient concerns or questions.