WEIGHT GAIN AND EDEMA
PATIENT INITIALS: Mrs. P. AGE: 55 SEX: FEMALE RACE: WHITE
CC: The patient came to the hospital for consultation regarding her hypothyroidism.
HISTORY OF PRESENT ILLNESS: This is a 55-year-old female with a history of I-131-induced hypothyroidism years ago who presents with increased weight and edema over the last few weeks with a 25-pound weight gain. She also has a diagnosis of fibromyalgia, inflammatory bowel disease, Crohn’s disease, COPD, and thyroid disorder as well as disc disease. She's found increased abdominal girth and increased edema in her legs. She has been in hypertension for years on Norvasc and lisinopril. She has intermittent sweats that have no noticeable improvement in her bowel condition. She takes away her Synthroid hormone from her. She's been on generic for the last couple of months and in the past has had problems with that.
MEDICATIONS: Levothyroxine 300 mcg daily, albuterol, Asacol, and Prilosec. Her amlodipine and lisinopril are on hold.
PAST MEDICAL HISTORY: Inflammatory bowel disease with Crohn, hypertension, fibromyalgia, COPD
PAST SURGICAL HISTORY: Hysterectomy and a cholecystectomy.
SOCIAL HISTORY: No smoking or drinking
FAMILY HISTORY: Positive for thyroid disease
REVIEW OF SYSTEMS: Positive for fatigue, sweats, and weight gain of 20 pounds. PHYSICAL EXAMINATION:
GENERAL: She is an obese female.
VITAL SIGNS: Blood pressure 140/70 and heart rate 84. She is afebrile.
HEENT: Extraocular movements were intact. There was moist oral mucosa.
NECK: Supple. Thyroid gland atrophic and nontender.
EXTREMITIES: Showed 1+ edema.
NEUROLOGIC: She was awake and alert.
LABORATORY DATA: TSH 0.28, free T4 1.34, total T4 12.4 and glucose 105.
IMPRESSION/PLAN: This is a 55-year-old female with weight gain and edema, as well as history of hypothyroidism. Hypothyroidism with the disorder Graves several years earlier is similar to radioactive iodine.
She is a euthyroid clinically and biochemically.
Her TSH is slightly suppressed, but her free T4 is fine,
and I will not decrease her levothyroxine dose with her weight gain.
I'm going to stay
On Synthroid 300 mcg daily.
If she wants to lose more weight, in six weeks ' time I
Would perform the thyroid function test to ensure she also isn't hyperactive thyroid.