CHART NOTE
A 34-year-old lady who comes to clinic today with longstanding history of hypothyroidism, for which she has taken Cytomel in the past. Comes in today for a refill of medication and further evaluation.
Examination shows her to be in no acute distress. Blood pressure 120/88. HEENT normal. Chest is clear. Cardiac examination reveals regular rate and rhythm without murmur.
ASSESSMENT
A 34-year-old lady with longstanding hypothyroidism. I would prefer to switch her to Synthroid 0.1 mg as I think the packaging is more uniform in this product. Then test thyroid-stimulating hormone in 1 month.
FOOTNOTE
Line 7. The article A was added to avoid beginning the sentence with a numeral.
Line 13. The blood pressure value 120 by 88 is written 120/88.
Line 18. A zero was inserted before the decimal point for clarity.
Lines 19, 20. TSH is expanded in the assessment for clarity.
No comments:
Post a Comment