Sick Visit: Management of Endocrine Conditions Shadow health

Sick Visit: Management of Endocrine Conditions Shadow health

Sick Visit: Management of Endocrine Conditions Shadow health

Sick Visit: Management of Endocrine Conditions Shadow health


Documentation / Electronic Health Record

  • Flowsheets
  • My Provider Notes
  • Diagnostic Notes
  Model Documentation

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

Student Documentation  

Subjective

Ms 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.

Records: Flowsheets, My Provider Notes, Diagnostic Notes

My Provider Notes
Model Documentation

Main Concern: “My hair is falling out, and I’m feeling tired” Current Issue: Maureen, a 79-year-old woman, is visiting the clinic today.

She has a non-injury-related hair loss for three weeks and fatigue persisting for a month. Her symptoms are ongoing, with no specific triggers. She also mentions dry skin on her hands, arms, and elbows that began three weeks ago. She applies lotion to relieve the dryness temporarily. Despite her symptoms, her daily activities are not affected.

Maureen takes her prescribed medications diligently, including Synthroid in the early morning, at least an hour apart from other medications or food. Her Synthroid medication was changed three months ago, with a new name (levothyroxine sodium) and pill shape (oblong).

She maintains her usual 7-8 hours of sleep per night and denies new stress or anxiety.

Home Medications:

• Multivitamin before bedtime

• Calcium tablet once a day

• Vitamin D tablet once a day

• Synthroid 125 mcg in the morning

Allergies: No known drug allergies.

Medical History: Hypothyroidism, weak bones (osteopenia).

Surgical History: No surgeries.

Lifestyle: Non-smoker, rare alcohol use during special occasions.

Nutrition: Adequate diet.

Student Documentation
Patient’s Experience

Ms. Hopkins, a 79-year-old woman, comes to the clinic, mentioning fatigue and hair loss as her main concerns.

She states these symptoms have persisted for nearly a month. She also notices her skin becoming dry and tries using lotion, but it only brings temporary relief. Despite her symptoms, she can manage her daily activities independently.

Ms. Hopkins has a history of hypothyroidism and weak bones (osteopenia). She regularly takes her medications, which include levothyroxine for hypothyroidism and supplements for osteopenia. She’s aware of the change in her Synthroid medication to levothyroxine.

She doesn’t associate her current symptoms with her existing conditions. Regarding allergies, she has none. Her current medications are levothyroxine 125 mcg, a daily calcium tablet, and a daily vitamin D tablet.

Her medical history includes a diagnosis of hypothyroidism 15 years ago and osteopenia 4 years ago. In her family history, her mother passed away due to a stroke, and her father had complications related to COPD. Socially, Ms. Hopkins is retired and lives independently.

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I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

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