HISTORY:
for
Worsening factors:
Alleviating factors: ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: -R: , -L: ,
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Skin:
Extremities: , , cap refill , pulses ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , ,
- Thyroid ultrasound
-
- Repeat TSH in
- Referral to endocrinologist
- Follow-up in
- Return if symptoms worsen or if side effects develop