Discussion Question 2
VG is a thirty-one-year-old female who comes in for a routine follow-up. She reports that she has been feeling excessive fatigue over the last month. She also notes that she is having some problems at work, not only because of her fatigue but also because of difficulty concentrating. She also notes that she has gained 10 pounds over the last month, and she is unable to identify the cause of the weight gain. She also notes that her periods are a little heavier and more irregular. She is currently taking daily ferrous sulfate and over-the-counter calcium. According to her medical record, she had a TSH level of 4.2 mIL/L about a year ago. Although this is slightly elevated, no further follow-up was deemed necessary at the time. Repeat blood work today reveals a TSH level of 9.8 mIL/L and a free T4 of 0.72 ng/dL. Answer the following questions:
For medications, include dosages and schedules. Include highlights of patient teaching and/or lifestyle alterations. Support your decisions with at least one reference to a published clinical guideline and one peer-reviewed publication, no more than 3 years old and APA format.
Expert Solution Preview
Introduction: This scenario involves a patient with symptoms of fatigue, weight gain, difficulty concentrating, and irregular periods. The patient’s lab work suggests hypothyroidism, and the questions relate to the appropriate management of this condition.
1. What additional findings on the physical exam would you look for?
In addition to assessing vital signs and general appearance, a physical exam should evaluate the thyroid gland for enlargement, nodules, or tenderness. Other signs of hypothyroidism, such as dry skin, brittle hair, and bradycardia, may also be present.
2. What implication does the previous TSH level have?
The previous slightly elevated TSH level, combined with the current markedly elevated TSH and low free T4 levels, strongly suggests that the patient has developed overt hypothyroidism. This is a common condition that can have significant effects on a person’s quality of life if left untreated.
3. What therapy would you institute?
The standard therapy for hypothyroidism is replacement with levothyroxine (L-T4) at a dose sufficient to normalize TSH levels. The typical starting dose is 1.6 mcg/kg body weight per day, although in older patients or those with cardiac disease, a lower dose may be appropriate. The patient should have repeat TSH levels checked in 4-6 weeks and the L-T4 dose adjusted as needed.
4. If VG becomes pregnant, what adjustment, if any, would be needed in her thyroid medication?
Pregnancy increases the demand for thyroid hormone, and many women require an increase in L-T4 dosing during pregnancy. The American Thyroid Association recommends testing for hypothyroidism at the initial prenatal visit, with repeat testing every 4 weeks until 20 weeks’ gestation, then again at 24-28 weeks and 32-34 weeks. The goal is to maintain TSH levels within the normal range for pregnancy, which may require as much as a 30-50% increase in L-T4 dosing. Close monitoring during pregnancy is essential to prevent adverse outcomes for both the mother and fetus.
1. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
2. Alexander EK, Pearce EN, Brent GA, et al. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid. 2017;27(3):315-389.