Diagnosis and Treatment of Hypothyroidism Patient Information: MJ, a 71-year-old, female, White origin

 
Expert Answer and Explanation
Diagnosis and Treatment of Hypothyroidism

Patient Information:

MJ, a 71-year-old, female, White origin

S

CC: “Fatigue and dry skin.”

HPI: MJ is a 71-year-old female of white origin who came to the office with concerns about dry skin and fatigue. She says that she has been feeling fatigued regardless of the amount of sleep she gets for the last five days. She also complains of thinning because of her meds. Associated symptoms include weight gain, constipation, increased sensitivity to cold, hoarseness, muscle weakness, muscle and joint aches, and a puffy face. She has not taken any medication to relieve the symptoms. She denies pain or falls.

Current Medications: Women’s One Day-Multivitamin daily, Fish Oil 1 tablet daily, Chlorthalidone 25mg daily, Amlodipine 5mg p.o. daily, Atorvastatin 40mg p.o. at bedtime daily, Losartan 100mg p.o. daily, Ergocalciferol 50,000 units PO once a month, and Aspirin 81mg p.o. daily

Allergies: I.V. Contrast, ACE Inhibitors

PMHx: She received the pneumonia vaccine three years ago. She does not remember information about the tetanus vaccine. Past medical illnesses include Vitamin D deficiency, Hyperlipidemia, and Hypertension.

Soc and Substance Hx: She is a retired Banker. She loves reading…