WRITING TEST: CASE NOTE 2

Patient's name: Charmaine Plantz

Age: 31
Sex: F
Occupation: Sales Manager

Present complaint: Lump on front of neck for one month

Other symptoms: Palpitations. Heat intolerance. Insomnia. Breathlessness. Increased bowel movements.
Light menstrual periods

Physical Examination: Enlarged thyroid, Tachycardia. Slight hypertension. Warm, moist, smooth skin.
Exophthalmus. Tremor. Weight loss. Muscle weakness. Hair loss.

Findings: Blood tests: Full Blood count: Normal

Urea and electrolytes: Normal
A Thyroid function test (TFT): TSH 0.01, T4 250

Diagnosis: Hyperthyroidism