Hypothyroidism with history of thyroiditis

VITAL SIGNS:  Temperature 97.3, pulse 76, respiration 16, and BP 152/104.  Weight 130 pounds.
GENERAL:  No acute distress.  A and O x3.
HEENT: Normocephalic and atraumatic.  Extraocular muscles are intact.  Pupils are equal, round, reactive to light, and accommodation.  Oropharynx is nonerythematous.  Mucous membranes are moist.
NECK: Supple.  I do not appreciate any thyroid nodules or thyromegaly on examination.
RESPIRATORY:  Nonlabored breathing.
PSYCHIATRIC:  Good affect.

 1.    Hypothyroidism with history of thyroiditis.  I have discussed the case with Dr. Christ and at this time we will not be performing a fine-needle biopsy.  However, I will be referring the patient to endocrinology.  I am ordering monthly TSH and free T4 and I am ordering thyroid antibodies and I am also ordering a thyroid radionuclide study as per radiology suggestion.  The patient is to follow up in 4 weeks or p.r.n. sooner.  I have also had attempted through for the patient' to ears, nose, and throat, Dr. Kimball at this time.  He states that the patient should be seen by endocrinology prior to seeing the ears, nose, and throat.  Therefore, I have referred the patient to endocrinology. We are awaiting the patient's appointment.
 

2.    Nausea.  I am going to be recheck a barium swallow study on the patient.
 

3.    Bilateral knee pain, left knee x-rays came back negative.  They showed no abnormalities.  I had prescribed the patient Tylenol Arthritis and Ultram.

The patient verbally understood all instructions at this time of visit.  She is to follow up in 4 weeks or p.r.n. sooner.

The above SOAP note was discussed with Dr. Accamma Joy who agrees with the above assessment and plan/