Chapter 11: The Endocrine System | Dorothy Frederick's Chart Note

CHART NOTE

Patient Name: Frederick, Dorothy
ID Number: 11472DR
Examination Date: November 23, 20xx

SUBJECTIVE
Dorothy is a 40-year-old music teacher here for follow-up of unusual irritability and fatigue over the past month. She also complains of anxiety and has noticed an intermittent rapid or irregular heartbeat. She said she always has a slight hand tremor, but it seems to be getting worse. She thinks the Paxil® (anti-anxiety medication) may be helping her sleep, but has not seen much of an improvement.

OBJECTIVE
Patient appears well. HEENT (head, eyes, ears, nose, and throat) are normal. A slightly enlarged thyroid is palpated. No adenopathy. There is a scar from a previous lymphadenectomy. Lungs are clear. Tachycardia noted. No edema of the lower extremities. Abdomen is soft and nontender. Lab report indicates a decreased TSH level. Other lab results were negative.

ASSESSMENT
Graves' disease

PLAN
Continue with Paxil for her anxiety and depression. She will be scheduled for a thyroid scan and ECG. I am referring her to an endocrinologist for further treatment.