Chief complaint: Lab work evaluation with fatigue and lack of motivation.

HPI: 53-year-old white female is experiencing fatigue with lack of motivation. Has a weight gain of 15 pounds despite yoga exercise 2-3 times a week. Lab work shows increased TSH. 

PMH: Last menstrual period 3 years ago. Has symptoms in the past of hot flashes and night sweats that resolved a couple of years ago.

Allergies: N/A

Medications: N/A

Social History: Teaches yoga 2-3 times a week.  

Family History: N/A

Review of Systems:

Constitutional: Weight gain of 15 pounds even though teaches yoga 2-3 times a week for the past few years.

Head: N/A

Eyes: N/A

Ears, Nose, Mouth, Throat: Denies difficulty swallowing.

Neck: Denies neck pain or tenderness.

Cardiovascular: N/A


Breast: N/A

Gastrointestinal: N/A

Genitourinary: N/A

Musculoskeletal: N/A

Integumentary: N/A

Neurological: N/A

Psychiatric: N/A

Endocrine: N/A

Hematologic: N/A

Allergic/Immunologic: N/A


HR: 60

RR: 16

BP: 145/88

Temp: 97.2

SPO2%: N/A

HT: 5’5

WT: 154 pds

BMI: 25.62

Age: 53

Sex: F

Pain: N/A

Physical Exam:

General Appearance: N/A

Head: N/A

Eyes: N/A

ENT, Mouth: N/A

Neck: Nontender, mild goiter with right side of goiter larger than the left side.

Cardiovascular: Regular heart rhythm without murmur or gallop.

Respiratory: Lungs clear.

Breast: N/A

Gastrointestinal: N/A

Genitourinary: N/A

Musculoskeletal: Slowed relaxation of Achilles tendon reflex. 

Integumentary: Dry on extremities with some flaking noted.

Neurological: N/A

Psychiatric: N/A

Endocrine: TSH 93.

Hematologic: N/A

Allergic/Immunologic: N/A


Diagnosis: The patient’s lab value of 93 for TSH indicates hypothyroidism. The patient has dry flaking skin. The blood pressure indicates hypertension stage 2 (American Heart Association, 2023). Patient will be evaluated to rule out Hashimoto’s thyroiditis. It is a chronic autoimmune inflammation that is most common in females. Some symptoms include fatigue, weakness, and constipation. In Hashimoto’s thyroiditis, TSH is typically slightly elevated (Salina et al., 2023). The patient has an extremely elevated TSH.

Therapeutics: Synthroid 100mcg a day (Arcangelo, et al., 2021). The patient will have a follow-up in 6-8 weeks. Hydrochlorothiazide 25mg per day (Mayo Clinic, 2023). The patient will have a follow up in 4 weeks.

Educational: Lifestyle changes encouraged to decrease weight and lower blood pressure. The patient will be educated on the side effects of Synthroid. This includes increased appetite, heat sensitivity, mood swings, and weight loss. Iron, calcium, and antacids can decrease the effectiveness of Synthroid, and supplements should be taken 4 hours before or after taking Synthroid. Long-term use of Synthroid can lead to osteoporosis and cause a bleeding risk. A drug list will be given show what drugs should be avoided. Drugs that increase adverse effects are amitriptyline, pseudoephedrine, albuterol, and ketamine (Arcangelo, et al., 2021).

Consultation/Collaboration: Endocrinology evaluation. Ultrasound of goiter ordered to evaluate the tissue.

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