HISTORY
This is a 68-year-old woman who was seen probably about 3 years ago with a large colloid goiter. She was going to have surgery then but declined and came back in more recently because of increasing size of the goiter and the pressure symptoms in her neck and throat. Studies previously done showed this to be a nontoxic goiter. She was essentially euthyroid. Because of its increasing size, the possibility of malignancy had to be considered.
Physical examination was not remarkable except the patient being somewhat overweight and the large goiter which was visible and the right side being larger than the left. The patient, because of religious customs, would not allow a pelvic or rectal examination.
Following surgery, the patient had no problem speaking. She is swallowing and eating solid food. Throat is sore. She did develop a temperature up to 101 and had some rhonchi in both bases on auscultation. Chest x-ray shows discoid atelectasis with probable pneumonitis. Her white count was elevated at a little over 12,000 with a left shift. Temperature this morning is 100 degrees. The wound is clean and dry. The drain has been removed, and one-half of the staples are removed. She will be continued on tetracycline 500 mg q.i.d., and she is instructed to take her Lanoxin daily and her Dyazide as well. We are giving her Synthroid, and she is to take that every day. I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function. Her calcium was 8.6.
FOOTNOTE
Line 11 (Page 1). The dictator said same for the Final Diagnosis, indicating it is the same as the Admitting Diagnosis. For clarity the Final Diagnosis should be repeated in full.
Line 37 (Page 1). Degrees was not dictated with the temperature of 101 but it is acceptable to add it to be consistent with the later expression.
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