Description
A.B. 46yo Hispanic Female 46 y/o for f/u with labs.
SUBJECTIVE:
Hypothyroidism: TSH (REFL): 0.34 L
Taking Levothyroixine 175 mcg QAM
Pt was off of Levothyroxine for 1.5 months and felt hypothyroidism symptoms at that time. Pt started taking it again 1 month ago.
Family losses since Sep 2023 causes bouts of crying, depressed mood.
Irregular periods:
LMP 1/8/24
Lasting more 14 days of periods and then she doesn’t get it 2-3 months. Sept/Oct/Nov no period. Dec 6 she got it for 8 days.
Cramps on right side, regardless of presence of period
First prescribed OCP for bleeding. Stopped taking birth control 1.5 years ago. Pt referred to Glendale for evaluation, cysts found. No further imaging was done.
Uses 5-6 super and regular tampons. Reports quarter sized clots.
sexually active, no contraceptive use, 1 partner
10 y/o menarche. No FHx of early menopause. Irregular sleep of 6 hours, chills. Denies hot flashes, night sweats, vaginal dryness.
Depression
Depression and anxiety
States she has been experiencing high stress and depressive mood from grieving over multiple family losses since Sep 2023.
Iron Deficiency Anemia
Iron deficiency anemia
Pt stopped taking iron supplements for the past year due to constipation
Screening
Mammogram scheduled 1/18/24
Denies breast changes or nipple discharge.
FOBT kits were sent to her in the past but she did not send them in or follow up on it. No h/o colonoscopy
Retinitis pigmentosa dx 3 years ago – Yearly screening. Jun 2023 last visit with stable result
allergy : Penicillin-hives
PMH:
Hypothyroid
IDA (iron deficiency anemia)
Constipation
Obesity
Anxiety
PSH:Thyroidectomy. 1999
Social Hx:
1-2 drinks, only socially
Quit smoking Oct 2023. Started smoking again 3 days ago, 1 cigarette a day
Leasing manager. Desk work some days and walking around properties other days.
Meds: Levothyroxine Sodium 175 MCG Tab sig: TAKE 1 TABLET BY MOUTH EVERY DAY IN THE MORNING ON EMPTY STOMACH
ROS:
General: Denies fevers or chills.
Diet: Less fruits and vegetables. Homecooked meals.
Exercise: No regular exercise.
Resp: Denies SOB, cough wheezing.
CVS: Denies chest pain or palpitations.
Breast: No pain, tenderness, or lumps. No breast asymmetry.
GI: Intermittent constipation. Denies nausea, vomiting, diarrhea.
GU: Denies dysuria, hematuria.
Endoc: Often feels cold. Denies weight change.
Psych: High stress and depressive mood from grieving over family losses since Sep 2023.
Objective:Vitals:
BP:107/61
HR:75
Temp:97.1 °F
RR18
Ht:61 in.
Wt:159 lbs.[-1 from 160 lbs on 08/11/2021]
BMI:30.04[-0.19 from 30.23 on 08/11/2021]
O2:97
GLUCOSE 130H
UREA NITROGEN (BUN) 10
CREATININE 0.52
EGFR 116
TSH 0.34
PE:
General: No acute distress.
Eyes: PERRLA
Neck: Flexible.
Resp: CTAB, No rales or rhonchi
CVS: RRR, No murmurs or gallops
Abdom: Soft, nontender
Skin: No rashes
