Endocrine Surgery Consult Note

Valmis merkintä

Endocrine Surgery Note

Patient Identification: adult patient presenting with a thyroid nodule and intermittent neck pressure.

History of Present Illness:
A thyroid nodule was found incidentally on imaging several months ago. The patient reports intermittent pressure when swallowing but no progressive dysphagia, breathing difficulty, or voice change. No prior neck irradiation or thyroid treatment.

Past Medical History:
- Mild asthma
- No prior surgeries

Medications:
- Albuterol inhaler as needed

Allergies:
- No known drug allergies

Family History:
- No known thyroid cancer or endocrine tumors

Social History:
- No tobacco use
- Occasional alcohol use
- No recreational drug use
- Works in an office
- Lives with family

Physical Examination:
- BP: 122/76 mmHg, HR: 72 bpm, T: 36.8 °C, RR: 14, O2 sats: 99%
- Well appearing
- Neck: Mobile, non-tender left thyroid nodule; no palpable cervical lymphadenopathy; voice clear
- No respiratory distress

Investigations:
- TSH: 1.8 mIU/L; calcium: 9.3 mg/dL
- Ultrasound: 2.4 cm solid left thyroid nodule; no suspicious lymph nodes
- Fine-needle aspiration: indeterminate cytology

Assessment & Plan:
adult patient with an indeterminate left thyroid nodule and mild pressure symptoms.

1) Thyroid nodule
- Review cytology and ultrasound at multidisciplinary conference.
- Discuss diagnostic lobectomy versus surveillance after review.
- Obtain any additional indicated preoperative evaluation.
- Reviewed expected benefits, risks, and alternatives; patient wishes to consider options.
- Follow up after conference; seek urgent care for new breathing or swallowing difficulty.

Havainnollistava tapaus, jossa potilastiedot ovat keksittyjä. Tämä ei ole oikea potilasasiakirja eikä kliinistä ohjeistusta. Tarkista jokainen merkintä oman vastaanottosi perusteella.

Merkinnän taustalla olevat kliiniset faktat

Uudelleen käytettävä pohjarakenne

Endocrine Surgery Note

Patient Identification: [Patient name, age, gender, relevant medical history, presenting complaint]

History of Present Illness:
[Detailed description of presenting symptoms, onset, duration, progression, associated features, previous interventions, and relevant endocrine history]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Previous surgeries]
- [Endocrine disorders]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug/other allergies or NKDA]

Family History:
(hyphenated list)
- [Endocrine disorders or relevant familial conditions]

Social History:
(hyphenated list)
- [Tobacco use]
- [Alcohol use]
- [Recreational drug use]
- [Occupation]
- [Living situation]

Physical Examination:
(hyphenated list)
- [Vital signs with units] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Neck: Inspection, palpation, masses, lymphadenopathy, voice changes]
- [Other relevant systems: findings]

Investigations:
(hyphenated list)
- [Laboratory results: thyroid function tests, calcium, PTH, etc.]
- [Imaging: ultrasound, CT, MRI, nuclear scans]
- [Other relevant investigations]

Assessment & Plan:
[One-sentence summary including age, sex, and primary endocrine diagnosis]

#) [Diagnosis or problem as numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered]
- [Surgical plan: procedure, approach, preoperative preparation]
- [Medical management]
- [Counselling provided]
- [Referrals to other specialties]
- [Follow up plan]
- [Return precautions]