DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman admitted through the emergency room for shoulder pain and back pain. Because of his shoulder pain and back pain, the patient was admitted for the rule-out myocardial infarction protocol. We will also see the patient for hyperthyroidism and diabetes mellitus. Apparently, the patient reported having hyperthyroid function test about three months ago. He was therefore sent to see Dr. Jane Doe who noted that the patient was in atrial fibrillation. However, about a week ago, the patient had thyroid uptake, which according to the patient’s report showed an uptake of less than 1%. The patient did not have any iodinated contrast prior to the thyroid uptake. The patient also has a known type 2 diabetes mellitus for about four or five years. He did have history of left heel ulcer that has healed. Currently, he does also have left leg cellulitis treated with oral antidiabetic agent. He does also have history of nonproliferative diabetic retinopathy.
PAST MEDICAL HISTORY: Chronic kidney disease, dyslipidemia, hypertension, coronary artery disease, and obstructive sleep apnea.
PAST SURGICAL HISTORY: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient does not drink alcohol and does not smoke.
REVIEW OF SYSTEMS: Please refer to chart.
ALLERGIES: Penicillin.
MEDICATIONS: As an outpatient, glyburide 5 mg twice a day, Diovan 160 mg once a day, Zaroxolyn 5 mg every day, Zocor 80 mg every day, Aldactone 25 mg every day, lisinopril 20 mg every day, Lasix 40 mg every day, NPH insulin 60 to 80 units twice a day, Humalog 35-50 units twice a day, aspirin 81 mg every day, fish oil, Coumadin and sotalol. Tapazole was prescribed, but the patient has not started Tapazole yet.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure was 142/54 with a pulse rate around 82 and temperature around 98.4.
GENERAL: The patient is in no distress, cheerful, alert, awake, oriented and coherent. He is obese.
NECK: There is no palpable goiter or thyroid nodule.
LUNGS: Clear.
HEART: Atrial fibrillation.
ABDOMEN: Soft and obese.
EXTREMITIES: Bilateral moderate pitting edema with phases of eczema. There was no skin break in the feet. There was an area of left cellulitis that was bandaged.
LABORATORY DATA: The TSH today was 2.690. Also, from today, the comprehensive metabolic profile showed a creatinine of 1.8, a glucose of 178, and a sodium of 136 and otherwise normal findings, including potassium of 4.2.
ASSESSMENT AND PLAN: The clinical picture is compatible with silent thyroiditis with hyperthyroid blood test about three months ago and normal blood tests now due to spontaneous resolution. This is also compatible with the patient’s reported thyroid uptake findings of less than 1%. Since the thyroid uptake is less than 1%, there is no indication for Tapazole. Moreover, the TSH has now normalized. Tapazole is not needed.
Thank you very much for referring this patient.
