Patient’s name: Sarah Welsh
Age: 45 years old female
Past medical history
Drug history and Allergies
You are Sarah Welsh, a 45-year-old woman calling to discuss your recent blood test results.
You were diagnosed with an underactive thyroid (hypothyroidism) 6 months ago because you were experiencing constant tiredness, dry skin, and constipation. Your symptoms have improved slightly since starting Levothyroxine, but you are still struggling with the same issues, and they are affecting your job as a medical secretary.
You recently had your medication dose increased from 100mcg to 125mcg three months ago, but you don’t feel much better. You are now worried about what might be causing this.
ONLY SAY THIS IF ASKED:
You take multivitamins with your thyroid medication in the morning because you thought vitamin deficiencies might be the cause of your symptoms.
Social History
Lifestyle: You live with your husband and two children. Your husband is very supportive and helps out at home.
Job: You work as a medical secretary, but your tiredness makes it hard to stay on top of your tasks, and you feel it is impacting your job performance.
Habits: You don’t smoke, and you don’t drink alcohol.
Menstrual History: Your do not see your periods but you think this is due to your Mirena coil for contraception.
Ideas, Concerns, and Expectations
Ideas: You suspect your symptoms could be due to a vitamin deficiency or the Levothyroxine dose needing adjustment.
Concerns: Your symptoms are affecting your ability to work, and you are worried this might continue.
Expectations: You want the doctor to explain your blood test results and help you feel better.