Sick Visit: Management of Endocrine Conditions Shadow health
My Provider Notes Model Documentation
Table of Contents
Primary Concern: “My hair is falling out, and I’m feeling very tired.” History of Current Health Issues: Maureen, a 79-year-old woman, has come to the clinic today because she’s been losing hair for three weeks without any obvious cause and has been feeling tired for the past month. She hasn’t noticed anything that makes her symptoms worse. Additionally, she mentions having dry skin on her hands, arms, and elbows for the past three weeks. Applying lotion helps temporarily. Despite these issues, she can still carry out her daily activities without any problems.
The patient says she’s been taking all her medications correctly, including her Synthroid, which she takes early in the morning, at least an hour before eating or taking other medications. She mentions that her Synthroid medication changed three months ago, with the pill now being called levothyroxine sodium and having an oblong shape instead of being circular. She continues to sleep her usual 7-8 hours per night and hasn’t experienced any new anxiety or stress. Her current medications include a multivitamin at bedtime, a calcium tablet daily, a vitamin D tablet daily, and Synthroid 125 mcg in the morning. She has no known allergies except for not knowing any allergies in the past.
Medical History: She has had hypothyroidism and osteopenia in the past.
Surgical History: She has never had any surgeries.
Social History: She doesn’t smoke or use recreational drugs, and she only drinks alcohol on special occasions, although she hasn’t had any recently. She also mentions her diet.
Student Documentation
Personal Observations
Ms. Hopkins, a 79-year-old woman, comes to the clinic complaining of feeling tired and losing hair. She says she’s had these symptoms for about four weeks now. She also notes that her skin is dry, and although she’s been using lotion, it hasn’t helped much. She can still manage her daily tasks independently. She has a history of hypothyroidism and osteopenia and takes medication for both conditions, including Levothyroxine for her thyroid and supplements for her bones. She recalls her Synthroid medication being changed to levothyroxine. She believes her current health issues are unrelated to her existing conditions. She denies any allergies and lists her current medications. In the past, she’s been diagnosed with hypothyroidism for 15 years and osteopenia for 4 years. In her family history, her mother died from a stroke, and her father passed away due to complications from COPD. She’s retired and lives alone. She also mentions her lifestyle habits.
Documentation / Electronic Health Record
My Provider Notes |
Model Documentation |
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Chief Complaint: “I’m losing hair and feel tired” History of Present Illness (HPI): Maureen is a 79-year-old female presenting to the clinic today with concerns of atraumatic hair loss for three weeks, and fatigue, which has been ongoing for the past month. She reports no aggravating factors for her symptoms. She also reports non-pruritic dry skin on her hands, arms, and elbows that began three weeks ago Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record. Lotion temporarily relieves this dryness. Her symptoms are constant, but do not affect her activities of daily living.
Patient reports that she is taking all of her medications as prescribed, including taking her Synthroid in the early AM, at least 60 minutes apart from any other medications or food. Mrs. Hopkins reports her Synthroid medication changed three months ago. The medication name on the pill bottle changed to levothyroxine sodium, and the pill shape changed from circular to oblong. She sleeps her usual 7-8 hours per night with no reported new anxiety or stress. Home Medications: • Multivitamin QHS • Calcium tablet QD • Vitamin D tablet QD • Synthroid 125 mcg QAM Allergies: NKDA, denies all other allergies Past Medical History (PMH): Hypothyroid, osteopenia Past Surgical History (PSH): Denies Social History: Denies tobacco or recreational drug use, endorses rare alcohol use on special occasions, but none recently. Reports eating
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SubjectiveMs Hopkins a79-year old woman presents to the client with a chief complaint of fatigue and hair loss. She reports to have been experiencing the symptoms for almost four weeks. She also states to have noted her skin is dry. She has been using lotion with little or no relief. She reporta she can do all things by herself. She has hypothyroidism and osteopenia. She reports to taking synthroid for her hypothyroidism and supplements for her osteopenia. She also reports to have nited her synthroid name change to levothyroxine. She believes her current conditions have been managed and are not related to the symptoms she is presenti g with. Allergies; Denies of any allergy Medications; Levothyroxine 125 mc, Calcimu tablet QD, vitamin D QD. Sick Visit: Management of Endocrine Conditions Shadow health Documentation / Electronic Health Record Past medical history; Hypothyroidism diagnised 15 years ago and osteopenia diagnosed 4 years ago. Family history; Mother deceased from stroke and father deceased due to COPD complications. Social Hx;Patient is retired and lives alone. She reports to have a
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