Chapter 11: The Endocrine System | Pamela Rolf's Chart Note

CHART NOTE

Patient Name: Rolf, Pamela
ID Number: 54773EG
Examination Date: April 14, 20xx

SUBJECTIVE
Pamela has edema of the hands and legs. She complains of being constantly tired and cold. She still has problems with constipation and some weight gain. She has no hot flashes or depression. She has been on Synthroid® 110 mcg (micrograms) daily.

OBJECTIVE
BP is 124/76. Weight is 175 pounds, which is about 5 pounds heavier than a month ago. HEENT is normal. Chest, lungs, and heart rate are normal. Thyroid is clear to palpation. No goiter detected.

ASSESSMENT
Hypothyroidism

PLAN
Patient scheduled for TSH test next week. She will continue with Synthroid 110 mcg daily. She will return in 2 weeks to discuss her test results.


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