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ENDOCRINOLOGY CLINIC FOLLOWUP NOTE
DATE OF VISIT: XX/XX/XXXX
SUBJECTIVE: The patient is a XX-year-old male who
returns for followup of thyroid problems. He has been doing fairly well otherwise.
OBJECTIVE: Vitals are normal. The head is normocephalic. Nose is normal. Throat is clear. Teeth tongue and gums are normal. Neck is supple. The chest is normal shape and symmetrical with good expansion. The lungs are clear on auscultation. The heart has a regular
rhythm; no murmurs. The abdomen is soft and nontender; no hepatosplenomegaly. The joints are normal. Peripheral
pulsations are normal. Skin is normal. Extremities have no edema. Neurological – Cranials are intact. Motor
and sensory are normal. Reflexes are normal.
ASSESSMENT: Incidental finding
of nodule in the left lobe of the thyroid on ultrasound; there are multiple solid small nodules. Nuclear scan is normal. Thyroglobulin level is normal. Microsomal antibodies are normal and so are the thyroid lab tests.
At this
time the patient is not symptomatic. There is no cervical lymphadenopathy.
I discussed the case with the family;
he came in with his wife. They seem to understand the plan very well. An order for an ultrasound in 6 months is requested.
PLAN:
1. Observe and repeat the ultrasound in 6 months.
2. A followup visit after the ultrasound.
3. The patient is to be seen and
followed.
Patient Name
Patient Medical Record Number
Please note:
All identifying information has been omitted from our sample reports to protect privacy of patients involved. Medical reports on our site are to be used for reference purposes with no guarantee of accuracy, for research of medical words, terminology and phrases. Please be aware that style, abbreviation expansion, and verbatim preferences vary from client to client, and therefore our sample reports may not demonstrate proper Medical Transcription Style. Before submitting any work, you should consult your Book of Style, client, or instructor for further direction. No copy of this material in whole or in part is to be made without written permission.
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