Comprehensive Functional Medicine Visit Note

Subjective Notes

• 14/05/2024: Functional medicine OT consult for chronic fatigue, brain fog, and impaired IADL performance.
• 14/05/2024: 42yo F (Sarah Jenkins, DOB: 12/08/1981, MRN: 492-817-33) presents with 6-month Hx of progressive daytime somnolence, cognitive fatigue, and diffuse myalgias limiting work endurance and home management. PMH: Hashimoto's thyroiditis, IBS-C. Meds: levothyroxine, magnesium citrate. Reports poor sleep hygiene, high occupational stress, and post-prandial bloating.

Current Medications

• levothyroxine (Synthroid®) 50 mcg PO QAM
• magnesium citrate 200 mg PO QHS

Vitals

• Weight: 68.5 kg, Height: 165 cm, BMI: 25.2 kg/m²

Objective Notes

• Alert, oriented x4, NAD. Mild psychomotor slowing noted during cognitive-occupational screening.
• RRR, normal S1/S2, no murmurs, rubs, or gallops. Capillary refill < 2 sec.
• CTAB, normal respiratory effort, no wheezes or rales.
• CN II-XII intact. 5/5 strength UE/LE bilaterally. Fine motor coordination intact; mild decrease in grip endurance bilaterally.

Notable Labs

• 07/05/2024
• TSH: 3.8 mIU/L, Free T3: 2.3 pg/mL, TPO Ab: 145 IU/mL, 25-OH Vitamin D: 22 ng/mL, Ferritin: 18 ng/mL, hs-CRP: 2.4 mg/L.

Assessment Section

Notes -

• Chronic fatigue syndrome / occupational performance deficit
• Hashimoto's thyroiditis (suboptimally controlled)
• Vitamin D deficiency
• Iron deficiency without anemia

Practitioner Recommendations

• For Vitamin D deficiency and fatigue:
  • Vitamin D deficiency
  • cholecalciferol (Vitamin D3):
  • Dose: cholecalciferol 5,000 IU PO QD with food
  • Side Effects/Expectations: Minimal risk at this dose; rare GI upset. Expect improved energy and immune modulation over 8–12 weeks.
  • Patient Decision: Agrees to initiate supplementation.
  • Recheck Labs: 25-OH Vitamin D in 12 weeks.
• For Iron deficiency and reduced physical endurance:
  • Iron deficiency without anemia
  • ferrous bisglycinate (Thorne Iron Bisglycinate):
  • Dose: ferrous bisglycinate 25 mg PO QOD with vitamin C
  • Side Effects/Expectations: Possible mild constipation or dark stools. Expect improved physical stamina and reduced brain fog in 6–8 weeks.
  • Patient Decision: Agrees to QOD dosing protocol.
  • Recheck Labs: CBC, ferritin, and iron panel in 12 weeks.

Lifestyle

• Trial 30-day gluten-free and dairy-free anti-inflammatory diet; increase hydration to 2.5 L water daily.
• Implement energy conservation and pacing strategies during IADLs; limit exercise to 20 mins low-impact walking or restorative yoga 4x/week to avoid post-exertional malaise.
• Establish strict sleep routine (screens off at 21:00, lights out at 22:00); incorporate 10 mins box breathing BID for autonomic regulation.

Patient Decision

• Patient verbalizes understanding and agrees to start cholecalciferol and ferrous bisglycinate, implement OT energy conservation techniques, and trial the elimination diet.

Follow-up

• Return to OT clinic in 4 weeks at 10:00 MST to review activity log, ergonomic modifications, and dietary adherence; coordinate thyroid medication adjustment with PCP.
• Call clinic or proceed to nearest ED if experiencing severe palpitations, chest pain, acute SOB, or syncope.