EBP CASE
Hypothyroidism
Log ID: 251107012548
, HPI ROS PE DX
CC: “I’ve been feeling very fatigued and have notice my hair is falling out”
HPI: 50-year-old female presents with complaints of fatigue and hair loss over
the past few months, which have been gradually worsening. She describes the
fatigue as a constant, persistent feeling of low energy that worsens towards the
end of the day. She rates the fatigue 5/10. Despite getting adequate sleep, the
fatigue does not improve. The symptoms have impacted her ability to
concentrate at work and perform daily tasks efficiently. She has also noticed
diffuse hair thinning. Hair loss is worse when brushing or washing her hair. She
reports weight gain but denies recent illness, fever, cold intolerance,
constipation, and dry skin. She has not tried any medications or supplements for
symptom relief. PMHx is significant for mild subclinical hypothyroidism and
perimenopause (LMP 12/1/24).
Hypothyroidism
Log ID: 251107012548
, HPI ROS PE DX
CC: “I’ve been feeling very fatigued and have notice my hair is falling out”
HPI: 50-year-old female presents with complaints of fatigue and hair loss over
the past few months, which have been gradually worsening. She describes the
fatigue as a constant, persistent feeling of low energy that worsens towards the
end of the day. She rates the fatigue 5/10. Despite getting adequate sleep, the
fatigue does not improve. The symptoms have impacted her ability to
concentrate at work and perform daily tasks efficiently. She has also noticed
diffuse hair thinning. Hair loss is worse when brushing or washing her hair. She
reports weight gain but denies recent illness, fever, cold intolerance,
constipation, and dry skin. She has not tried any medications or supplements for
symptom relief. PMHx is significant for mild subclinical hypothyroidism and
perimenopause (LMP 12/1/24).
