HYPOTHYRO

Members:
IDISM
Banquil, Jonah Mae
Cruspero, Vylyn
Ellorimo, Arnie
Jabon, Mitchell
Mawali, Merriam
 “I always feel so tired lately.
CHIEF COMPLAINT:
Maybe I’m working too hard?”

HISTORY OF PRESENT
ILLNESS:
PAST MEDICAL HISTORY:
 Iron deficiency anemia × 6 months
 Depression × 6 months
 Menorrhagia × 4 months

FAMILY HISTORY:
 Positive for CVD, CAD
 Father had Type 2 DM and died of CVA at age 55
 Mother is alive with Type 2 DM, HTN, and hypothyroidism and
 had an MI at 60
 She has one brother with Type 2 DM and a sister with HTN.

SOCIAL HISTORY:
 Married, lives with her husband of 20 years; has two children
aged 16 and 12.
 Works as a financial advisor for a large bank.
 NS:
 MOM 30 mL po daily PRN constipation
 Fluoxetine 20 mg po daily
 Ortho Tri-Cyclen-28 1 po daily
 FeSO4 300 mg po daily
 Calcium carbonate 500 mg po twice
daily
 Acetaminophen 325–650 mg po PRN
headache, body aches
ALLERGY:
 NO KNOWN DRUG ALLERGIES
EVIEW OF SYSTEM:
 Occasional headaches relieved with non-aspirin pain reliever
 (–) tinnitus, vertigo, or infections;
 frequent body aches which she attributes to lack of exercise;
 (–) change in urinary frequency, but she has noticed an
 increase in the number of episodes of constipation in the past year;
reports cold extremities;
 (–) history of seizures, syncope, or LOC, (+) dry skin
PHYSICAL EXAMINATION:
 General appearance:
Well-appearing, middle-aged, Hispanic woman in NAD
 VITAL SIGNS:
 Blood pressure: 142/89 (above normal; 120/80)
 Pulse rate: 64 (Normal)
 Respiratory rate: 18 (Normal)
 Temperature: 36.4°C (Normal)
 Weight: 68 kg
 Height: 5’4 - BMI: 25.7 (Overweight)
 Skin:
Dry appearing skin and scalp; (–) rashes or lesions
 HEENT:
PERRLA, EOMI; trace periorbital edema; (–) sinus tenderness;
TMs appear normal
PHYSICAL EXAMINATION:
 Neck/Lymph Nodes:
(–) thyroid nodules or goiter; (–) lymphadenopathy, (–) carotid
bruits
 Lungs/Thorax:
CTA
 Breasts:
(–) lumps/masses
 CV:
RRR normal S1, S2; (–) S3 or S4
 Abd:
NT/ND, (–) organomegaly
 Neurological:
A & O × 3; CN II–XII intact; DTRs 2+, symmetric
LABORATORY:
PATIENT’SLABORATORYTEST: NORMAL VALUES:
Na 142 mEq/ L Normal 135-144 mEq/ L
K 4.1 mEq/ L Normal 3.5-4.8 mEq/ L
Cl 100 mEq/ L Normal 97-106 mEq/ L
CO2 24 mEq/ L Normal 22-32 mEq/ L
BUN 9 mg/ dL Normal 7-20 mg/ dL
Scr 0.8 mg/ dL Below Normal 0.9-1.3 mg/ dL
Glu 104 mg/ dL Normal < 140 mg/ dL
LABORATORY:
PATIENT’SLABORATORYTEST: NORMAL VALUES:
Hgb 13.6 g/ dl Below Normal 13.8-17.2 g/ dL
Hct 40.1% Below Normal 41%-50%
WBC 7.6 x 103 / mm3 Normal 4.5 – 11.0x109/ L
MCV 83 μm3 Normal 80-96
Ca 9.4 mg/ dL Normal 8.5-10.8 mg/ dL
Mg 1.8 mEq/ L Normal 1.5-2.2mEq/ L
PO4 3.8 mg/ dL Normal 2.5-4.5 mg/ dL
LABORATORY:
PATIENT’SLABORATORYTEST: NORMAL VALUES:
Anti-TPO antibody + >30 IU/ mL
TSH 12.8 mIU/L Above Normal 0.5-5.0 mIU/ L
Free T4 0.71 ng/dL Below Normal 0.8-1.8 (ng/ dL
T. chol 268 mg/dL Above Normal <200 (mg/ dL)
LDL chol 142 mg/dL Above Normal <100 (mg/ dL)
HDL chol 36 mg/dL Below Normal 40 mg/ dL or higher
ASSESSMENT:
45-year-old woman with signs, symptoms, and
laboratory tests consistent with hypothyroidism.
QUESTIONS:
 PROBLEM IDENTIFICATION:

1.a. Identify this patient’s drug therapy problems.

 Milk of Magnesia
 Aluminum, calcium, iron, lanthanum, magnesium, simethicone,
and sucralfate
decreases the amount of thyroid medicine your body absorbs.
 Fluoxetine
 Associated with clinically significant changes in thyroid function
or thyroid autoimmunity in either primary hypothyroid or
normal thyroid function patients with depression.
 Ortho Tri-Cyclen-28
 Taking thyroid medicines with estrogens may decrease the
QUESTIONS:
 PROBLEM IDENTIFICATION:

1.a. Identify this patient’s drug therapy problems.

 FeSO4
 Ferrous sulfate may reduce the gastrointestinal absorption of
orally administered levothyroxine sodium in patients with
primary hypothyroidism. We describe a patient who became
hypothyroid while taking ferrous sulfate.
 Calcium carbonate
 Blocking the absorption of levothyroxine.
 Acetaminophen
 It can theoretically impair thyroid hormone signaling.
QUESTIONS:
 PROBLEM IDENTIFICATION:

1.b. What information (signs, symptoms, laboratory values)

indicates the presence of hypothyroidism?

 Patient manifestations include cold intolerance, constipation,

weakness and fatigue
 Review of system also presented dry appearing skin and scalp
 Laboratory test shown rise in TSH level,T4 below normal level
evident for hypothyroidism
QUESTIONS:
 PROBLEM IDENTIFICATION:

1.c. List examples of medications that are known to cause

hypothyroidism. Could any of the patient’s complaints have been
caused by drug therapy?

 Cholestyramine, Calcium Carbonate, Sucralfate, Aluminum

hydroxide, and Ferrous sulfate impair absorption of levothyroxine
from GI tract
 Rifampin, carbamazepine and possibly phenytoin increase
nondeiodinative T4 clearance
 Amiodarone – blocks T4 to T3 conversion
QUESTIONS:
 THERAPEUTIC ALTERNATIVES:

3.a. What nondrug therapies might be useful for this patient?

 Change of diet
 Sugar free foods
 Vitamin b12 rich foods
 Selenium rich foods
 Gluten free
 Probiotics
QUESTIONS:
 THERAPEUTIC ALTERNATIVES:

3.b. What feasible pharmacotherapeutic alternatives (including

complementary/alternative medicine products) are available for tr
of
hypothyroidism?

 Thyroid, USP (or desiccated thyroid) is derived from hog, beef, or

sheep thyroid gland. It may be antigenic in allergic or sensitive
patients. Inexpensive generic brands may not be bioequivalent.
 Thyroglobulin is a purified hog-gland extract that is standardized
biologically to give a T4:T3 ratio of 2.5:1. It has no clinical
advantages and is not widely used.
QUESTIONS:
 THERAPEUTIC ALTERNATIVES:

3.b. What feasible pharmacotherapeutic alternatives (including

complementary/alternative medicine products) are available for tr
of
hypothyroidism?

 Liothyronine (synthetic T3) has uniform potency but has a higher

incidence of cardiac adverse effects, higher cost, and difficulty in
monitoring with conventional laboratory tests.
 Liotrix (synthetic T4:T3 in a 4:1 ratio) is chemically stable, pure, and h
predictable potency but is expensive. It lacks therapeutic rationale becau
about 35% of T4 is converted to T3 peripherally.
QUESTIONS:
 OPTIMAL PLAN:

4. What drug, dosage form, product, dose, schedule, and

duration of therapy are best for this patient?

 Levothyroxine (L-thyroxine, T4) is the drug of choice for thyroid

hormone replacement and suppressive therapy because it is
chemically stable, relatively inexpensive, free of antigenicity,
and has uniform potency;
 Maintenance dose is about 125 mcg/day, but still need for
individualized therapy and monitoring to determine appropriate
dose.
QUESTIONS:
 OPTIMAL PLAN:

4. What drug, dosage form, product, dose, schedule, and

duration of therapy are best for this patient?

 Thyroid panel/profile should be checked every 4-6 weeks

 Once a normal TSH level is achieved it should be checked every 6
months thereafter.
QUESTIONS:
 OUTCOME EVALUATION:

5. What clinical and laboratory parameters are necessary to

evaluate thyroid replacement therapy to achieve euthyroidism
and prevent adverse effects?

 Both hyperthyroidism and hypothyroidism can also be caused by

thyroiditis, thyroid cancer, and excessive or deficient production of TSH.
thyroid panel may be used to evaluate thyroid function and/or help
diagnose thyroid disorders. Typically, the preferred initial test for thyroid
disorders is a TSH test.
QUESTIONS:
 OUTCOME EVALUATION:

5. What clinical and laboratory parameters are necessary to

evaluate thyroid replacement therapy to achieve euthyroidism
and prevent adverse effects?

 The normal range of TSH levels is 0.4 to 4.0 milli-international units p

liter. If you're already being treated for a thyroid disorder, the normal ran
is 0.5 to 3.0 milli-international units per liter. A value above the normal
range usually indicates that the thyroid is underactive. This
indicates hypothyroidism.
QUESTIONS:
 PATIENT EDUCATION:

6. What information should be provided to the patient to enhance

adherence, ensure successful therapy, and minimize adverse effect

 Take your medicine the same time every day.

 Keep your pills in a container that is labeled with the days of the week
This will help you remember if you’ve taken your medicine each day.
 Take your medicine with a full glass of water. Take it at least 1 before
eat breakfast. Or at bedtime, at least 3 hours after eating.
 Do not take calcium or iron within 4 hours of taking your thyroid medic
And, ask your healthcare provider about taking other medicines with you
thyroid pill.
QUESTIONS:
 PATIENT EDUCATION:

6. What information should be provided to the patient to enhance

adherence, ensure successful therapy, and minimize adverse effect

 Your healthcare provider will regularly check your thyroid

hormone levels with blood tests. If your dose is changed, you
will usually have lab work in 4 to 6 weeks to be sure that the
new dose is right for you.
 Always alert your healthcare providers of changes in your other
medicines (including estrogens, testosterone, and anti-seizure
medicines) as these changes may affect your thyroid hormone
levels.
FOLLOW-UP
QUESTIONS:
1. How should this patient’s elevated cholesterol and
BP be managed now? What if her cholesterol and BP
continue to be elevated
after she becomes euthyroid?

The patient should consult the physician if her

cholesterol levels does not go normal despite of being
euthyroid so that she can take proper drugs to stabilize
her lipids such as statin drugs. The family has history of
hypertension therefore, she has higher risk of developing
CVD that’s why she should regularly check her BP since
she is now in the borderline HTN (prehypertensive state).
And of course change in lifestyle and proper nutrition and
FOLLOW-UP
QUESTIONS:
2. Evaluate this patient’s continued need for ferrous
sulfate therapy.
Can it be discontinued? If not, what potential problems (if
any)
might be expected once thyroid replacement therapy is
started?

If she will take Levothyroxine she is advised to stop or

discontinue since FeSO4 can impair the absorption of
Levothyroxine and can render the therapy useless. Her Hgb
and Hct are near the borderline therefore she can switch to
iron supplements instead.
FOLLOW-UP
QUESTIONS:
3. Evaluate this patient’s continued need for
hormonal contraception. What potential problems (if
any) might occur if the contraceptive is discontinued
after her LT4 dose has been stabilized?
Birth control pills (oral contraceptives)can alter that
delicate balance of free and bound thyroid hormone in
your body. The estrogen in birth control pills increases
the amount of thyroid binding proteins available to bind to
thyroid hormone. Therefore the patient should
discontinue oral contraceptive; Stopping any form of
hormonal birth control removes external sources of
progesterone or progesterone and estrogen. This
changes the levels of these hormones in the body, which
 FOLLOW-UP
QUESTIONS:
4. How could you determine if the patient requires
continued
antidepressant therapy?

Major depressive disorder (MDD) is potentially a long-term or even

lifelong illness for many patients, and maintenance therapy is
designed to prevent relapse in patients with recurrent depression who
have achieved remission. Patients who have residual symptoms or
comorbid illnesses are among the suitable candidates for
maintenance treatment. According to Dr Keller says that continuation
therapy is intended to prevent relapse, that is, to suppress the
symptoms of a current depressive episode from which the patient has
not fully recovered. Usually, continuation therapy lasts 4 to 6 months
after a patient has responded in the acute phase of treatment.
 FOLLOW-UP
QUESTIONS:
4. How could you determine if the patient requires
continued
antidepressant therapy?

In continuation therapy studies, typical study design is to include

patients who responded to an antidepressant during the acute phase
and then to continue some patients on antidepressant therapy and
switch others to placebo. Antidepressant continuation therapy is in
variably more effective than placebo, illustrating the need for
continuation therapy with all treatments, including psychotherapy.
 E-Health Subjective Objective Assessment Plan FAQs

GOOGLE
Hyperthyroidism

Case Study Group 5

Members
Santiago Cutarra Dacumos Guillena Ganza Privacy Terms Settings
E-Health Subjective Objective Assessment Plan FAQs Hyperthyroidism

HYPERTHYROIDISM
Overview
Symptoms Signs
Hyperthyroidism occurs when the thyroid gland
produces too much thyroid hormone. In its
 Nervousness
mildest form, hyperthyroidism may not cause
noticeable symptoms. However, in some  Anxiety
patients, excess thyroid hormone and the
resulting effects on the body can have significant  Palpitations
consequences.  Emotional Lability
Hyperthyroidism can be caused by a number of  Easy Fatigability
things:
•Toxic Nodule  Menstrual Disturbances
•Toxic Multinodular Goiter  Heat Intolerance
•Graves’ Disease
•Sub-acute thyroiditis  Weight loss despite
WHAT IS
•Postpartum thyroiditis
HYPERTHYROIDISM? normal/increased appetite
•Excessive Iodine ingestion
WHAT ARE ITS SIGNS AND
•Over medication with thyroid hormone
SYMPTOMS?
E-Health Subjective Objective Assessment Plan FAQs Hyperthyroidism

HYPERTHYROIDISM
Overview
Symptoms Signs
Hyperthyroidism occurs when the thyroid gland
produces too much thyroid hormone. In its  Warm, moist skin
mildest form, hyperthyroidism may not cause  Exophthalmos
noticeable symptoms. However, in some  Pretibial myxedema
patients, excess thyroid hormone and the  Unusual fine hair
resulting effects on the body can have significant  Separation of the end of
consequences. fingernails
 Retraction of eyelids
Hyperthyroidism can be caused by a number of  Lagging of upper lid (lid lag)
things:
 Hyperdynamic circulatory state
•Toxic Nodule
(tachycardia at rest)
•Toxic Multinodular Goiter
 Widened pulse pressure
•Graves’ Disease
•Sub-acute thyroiditis  Systolic ejection murmur
WHAT IS  Fine tremors (tongue and
•Postpartum thyroiditis
HYPERTHYROIDISM? outstretched hands
•Excessive Iodine ingestion
WHAT ARE ITS SIGNS AND  Hyperactive Deep Tendon (knees)
•Over medication with thyroid hormone
SYMPTOMS?  Enlarged thyroid
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Chief Complaint: “My heart feels like it is racing and beating out of my chest.”

History of Present Illness Allergies Review of Systems

Past Medical Social History
Debbie James is a 32-year-old woman who
History
returns to her PCP with complaints of worsening
palpitations and continuing shortness of breath Not Significant - Lives w/ husband
with exertion. She saw the PCP 2 weeks ago for
Family History - Two daughters (7
the shortness of breath and was diagnosed with
& 5 y/o)
bronchitis. Despite treatment with an antibiotic Father: HTN
and an inhaler, the symptoms have not resolved. - Does not smoke
The palpitations started a few months ago and Mother:
Name: Debbie James Hyperthyroidism
Age: 32 would come and go until the past week when - Drinks alcohol
History of Ovarian
they began occurring more frequently, almost socially
Gender: Female Cyst (Hysterectomy)
Weight: 58 kg daily. She denies CP. She reports a 10-kg weight
Height: 5’6” loss over the past 2 months, despite a good
Current Medications
BMI: 19.9 kg/m2 appetite. She feels hot all of the time and
(Normal) sweats a lot. She also reports that she has been Multivitamins (Daily)
losing her hair recently and that that she is more
irritable than usual.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Chief Complaint

Patient Medical History Allergies Review of Systems

Sulfa Drugs
(Rashes)
Name: Debbie James
Age: 32
Gender: Female
Weight: 58 kg
Height: 5’6”
BMI: 19.9 kg/m2
(Normal)
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Chief Complaint

Patient Medical History Allergies Review of Systems

. Hair
More fine
Thinner
. Ocular
No visual changes
Name: Debbie James
.Respiratory
Age: 32 No CP
Gender: Female No dyspnea
Weight:
Height:
BMI:
58 kg
5’6”
19.9 kg/m2
.Gastrointestinal
(Normal) Occasional N/V/D
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Patient is a thin, tan-appearing WF in NAD
Vital Signs

HNT Examination Skin

Neck/Lymph Node  Hyperpigmented on upper
Lungs back and lower extremities
 Warm and moist
Cardiovascular
Abdomen Hair
Name: Debbie James Genitalia/Rectal
Age: 32 Extremities
Gender: Female  Fine and sparse in the
Weight: 58 kg Neurologic frontal area.
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Vital Signs
Vital Signs

HNT Examination
Blood Pressure: 130/78 ELEVATED
Name: Neck/Lymph Node
Age:
Gender: Lungs Pulse: 120 – 160 bpm TACHYCARDIC
Weight: Cardiovascular
Height:
BMI: Abdomen Respiratory Rate: 20 breaths/min NORMAL
Name: Debbie James Genitalia/Rectal
Age: 32 Extremities Temperature: 38.1° C FEVER
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
HNT Examination
Vital Signs

HNT Examination  Pupils are Equal, Round and

Name: Neck/Lymph Node React to Light (PERRL)
Age:
Gender: Lungs  Extra Ocular Movements Intact
Weight:
Height:
Cardiovascular (EOMI)
BMI: Abdomen  (+) lid lag
Name:
Age:
Debbie James
32
Genitalia/Rectal
 mild proptosis (no
Extremities
Gender: Female ophthalmoplegia)
Weight: 58 kg Neurologic
Height: 5’6”
Laboratory Results
 mild lid retraction
BMI: 19.9 kg/m2
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Neck/Lymph Node Examination
Vital Signs

HNT Examination
 Supple
Name: Neck/Lymph Node  (+) smooth
Age:
Gender: Lungs  symmetrically
Weight:
Height:
Cardiovascular enlarged thyroid
BMI: Abdomen
 (+) thyroid bruit
Genitalia/Rectal
Name:
Age:
Debbie James
32
 prominent
Extremities
Gender: Female pulsations in
Weight: 58 kg Neurologic
Height: 5’6” neck vessels
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Lungs Examination
Vital Signs

HNT Examination

Name: Neck/Lymph Node

Age:
Gender: Lungs  CTA bilaterally
Weight:
Height:
Cardiovascular  no wheezes or
BMI: Abdomen rales
Name: Debbie James Genitalia/Rectal
Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Cardiovascular Examination
Vital Signs

HNT Examination
 Irregularly irregular
Name: Neck/Lymph Node
Age:
rhythm
Gender: Lungs  tachycardic without
Weight:
Height:
Cardiovascular murmurs
BMI: Abdomen  (+) carotid bruits
Name: Debbie James Genitalia/Rectal bilaterally
Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Abdomen Examination
Vital Signs

HNT Examination
 Soft, Nontender
Name: Neck/Lymph Node (NT)/No Distension (ND)
Age:
Gender: Lungs  (+) Bowel Sound
Weight: Cardiovascular  no Hepatoslenomegaly
Height: (HSM) or masses
BMI: Abdomen
 Aortic pulsations
Name: Debbie James Genitalia/Rectal
palpable
Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Genitalia/Rectal Examination
Vital Signs

HNT Examination

Name: Neck/Lymph Node

Age:
Gender: Lungs  Guaiac (–)
Weight:
Height:
Cardiovascular stool
BMI: Abdomen

Name: Debbie James Genitalia/Rectal

Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Extremities Examination
Vital Signs

HNT Examination
 2+ DP pulses
Name: Neck/Lymph Node bilaterally
Age:
Lungs  No calf tenderness
Gender:
Weight:  No cyanosis
Cardiovascular
Height:  Fingernails and
BMI: Abdomen
toenails are flaking
Name: Debbie James Genitalia/Rectal  Thumbnails have
Age: 32 Extremities prominent ridges.
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination
Neurologic Examination
Vital Signs

HNT Examination
 A&O×3
Name: Neck/Lymph Node -Alert and Oriented to
Age: person, place and time
Gender: Lungs
 Fine tremor with
Weight: Cardiovascular outstretched hands
Height:
 Hyperreflexia at knees
BMI: Abdomen
 No proximal muscle
Name: Debbie James Genitalia/Rectal weakness
Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination Laboratory Results

Vital Signs
Lab Test Normal Values Result
HNT Examination
RBC 3.95-5.35 M/mm3 3.24 × 10^6 /mm3
Name: Neck/Lymph Node
MCHC 33.4 - 35.5 g/dL 32.4 g/dL
Age:
Gender: Lungs
T. Bili 0.2-1.3 mg/dL 0.1 mg/dL
Weight: Cardiovascular Total T4 4.5-12 mcg/dL 18 mcg/dL
Height:
BMI: Abdomen TSH 0.35-6.20 mUI/L <0.018 mIU/L
Name: Debbie James Genitalia/Rectal Total T3 71-180 ng/dL 368 ng/dL
Age: 32 Extremities Free thyroxine
Gender: Female 6.5-12.5 28.7
Neurologic index
Weight: 58 kg
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Physical Examination ECG Results

Vital Signs

HNT Examination
 Atrial fibrillation, with ventricular
Name: Neck/Lymph Node
Age: response of 130 bpm
Gender: Lungs
Weight: Cardiovascular
Height: Note:
BMI: Abdomen Normal Ventricular Rate: 60-100 bpm
Name: Debbie James Genitalia/Rectal
Age: 32 Extremities
Gender: Female
Weight: 58 kg Neurologic
Height: 5’6”
BMI: 19.9 kg/m2 Laboratory Results
(Normal)
ECG
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

Name: 32-year-old white woman with goiter,

Age:
Gender: probable hyperthyroidism, and new
Weight:
Height:
onset atrial fibrillation. Most likely
BMI: cause is Graves’ disease.
Name: Debbie James
Age: 32
Gender: Female
Weight: 58 kg
Height: 5’6”
BMI: 19.9 kg/m2
(Normal)
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

 The primary treatment goals are to reduce the amount of thyroid hormones that the
body produces and lessen severity of symptoms.
 Control bronchitis through administration of non-adrenergic agonist medications such as
inhaled corticosteroid (since the patient has experienced hyperdynamic circulatory state or
Name:
fast heart rate)
Age:
Gender:  Regulate the hyperdynamic circulatory state of the patient such as tachycardia even at rest
Weight:
through co-administration of selective beta-1 adrenergic blockers such as atenolol or
Height:
BMI: metoprolol.

Name: Debbie James (Note: Administration of nonselective beta-blocker for this affects the lungs thereby
Age: 32 precipitating to worsening of the bronchospasm)
Gender: Female
Weight: 58 kg  Reduce Total T4 and Free thyroxine index with non-sulfa containing medications such as
Height: 5’6” Iodides since the patient has been noted to developed rashes with sulfa-containing
BMI: 19.9 kg/m2
(Normal) medications (e.g. Propylthiouracil, methimazole)
 Increase TSH
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

PROBLEM IDENTIFICATION DESIRED OUTCOME THERAPEUTIC ALTERNATIVES >

1.a. Create a list of the patient’s drug therapy problems.

Name:
Age:
 Antibiotic (Sulfa- containing) - since the patient is allergic to sulfa
Gender: drugs.
Weight:
Height:  Inhaler (adrenergic agonist)- one of the side effect is increases
BMI:
heart rate. This may worsen the patient fast heart rate.
Name: Debbie James
 Multivitamins(iodine containing)- Too much iodine can make
Age: 32
Gender: Female hyperthyroidism worse by leading the thyroid gland to produce too
Weight: 58 kg
Height: 5’6” much thyroid hormone.
BMI: 19.9 kg/m2
(Normal)
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

PROBLEM IDENTIFICATION DESIRED OUTCOME THERAPEUTIC ALTERNATIVES >

1.b. What signs, symptoms, and laboratory values indicate the presence or severity of
hyperthyroidism.
Name: Lab Test Normal Values Result
Signs and symptoms:
Age:
Gender:  Palpitation Total T4 4.5-12 mcg/dL 18 mcg/dL
Weight:  Shortness of breath TSH 0.35-6.20 mUI/L <0.018 mIU/L
Height:
BMI:  Weight loss over the past 2 months
Total T3 71-180 ng/dL 368 ng/dL
 She feels hot all the time
Name: Debbie James Free
Age: 32  Sweat a lot thyroxine 6.5-12.5 28.7
Gender: Female index
 Losing hair recently
Weight: 58 kg
Height: 5’6” Family history: Her mother has Graves’ disease
BMI: 19.9 kg/m2
(Normal) Neck/ Lymph nodes: Symmetrically enlarged thyroid
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

PROBLEM IDENTIFICATION DESIRED OUTCOME THERAPEUTIC ALTERNATIVES >

2. What are the goals of pharmacotherapy in this case?

Name:  Normalize the production of thyroid hormone

Age:  Minimize symptoms and long-term consequences
Gender:
Weight:  Regulate the hyperdynamic circulatory state such as:
Height:
BMI: 1. Palpitation

Name: Debbie James 2. SOB

Age: 32  Prevent disease progression that could progress to severe:
Gender: Female
Weight: 58 kg 1. Weight loss
Height: 5’6”
BMI: 19.9 kg/m2 2. Intolerance to heat
(Normal)
3. Hair loss
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

PROBLEM IDENTIFICATION DESIRED OUTCOME THERAPEUTIC ALTERNATIVES >

3.a. What non-drug therapies and 3.b. What feasible pharmacotherapeutic

instruction might be useful for this alternative are available for the treatment
Name: patient? of hyperthyroidism for this patient.
Age:
Gender: The known non-drug therapy for  B-blockers (selective Beta 1-blockers)
Weight: Hyperthyroidism is surgical removal of the (Note: Since the patient has bronchitis –
Height:
BMI: thyroid or Thyroidectomy. However, it is administering nonselective beta-blockers
only considered when the thyroid gland is could worsen its symptoms)
Name: Debbie James
Age: 32 large enough (>80 grams) and if there is  Radioactive Iodide (RAI)
Gender: Female
severe ophthalmopathy or lack of  Centrally acting sympatholytics (e.g
Weight: 58 kg
Height: 5’6” remission on antithyroid drug treatment, clonidine),
BMI: 19.9 kg/m2
(Normal)
and patients with unstable heart  Calcium Channel Blocker (e.g diltiazem)
condition.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

OPTIMAL PLAN OUTCOME EVALUATION PATIENT EDUCATION >

DRUG, DOSAGE FORM,SCHEDULE AND DURATION OF THERAPY

DRUG DOSAGE FORM SCHEDULE AND DURATION OF THERAPY

Name: As 5% w/v iodine with 10% w/v K iodide
Age: solution: 0.1-0.3 mL in milk or water 3x
Gender: day for 6 days.
Weight: Iodides Solution Note: If the level of T3 and T4 haven’t
Height: decreased in one week, we will suggest
BMI: the patient for radioactive therapy or
surgery.
Name: Debbie James
Age: 32 Selective Beta 1-
Gender: Female blockers Tablet 25 to 100 mg orally once per day
Weight: 58 kg (Atenolol)
Height: 5’6” Iron supplement Tablet 1 tablet daily
BMI: 19.9 kg/m2
(Normal) Paracetamol Tablet As needed
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

OPTIMAL PLAN OUTCOME EVALUATION PATIENT EDUCATION >

 The parameters that are necessary to evaluate in order to evaluate the response
to therapy are the patient’s laboratory results specifically those thyroid
Name:
Age: hormones which increased because of her condition. These hormones needs to
Gender:
Weight: reduce closer to normal range to record an improvement.
Height:  Vital signs should be normalized with appropriate therapy.
BMI:
 Question the patient to detect any unusual side effects related to the drug or
Name: Debbie James
Age: 32 infusion (e.g., rash, nausea, vomiting, diarrhea) daily for the first 3–5 days and
Gender: Female then weekly thereafter.
Weight: 58 kg
Height: 5’6”  Improvement with vital signs.
BMI: 19.9 kg/m2
(Normal)
 Prevent enlargement of her goiter as well as control her onset atrial fibrillation.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

OPTIMAL PLAN OUTCOME EVALUATION PATIENT EDUCATION >

 The patient should return to clinic the next week to make sure that the

Name:
drug is working. At these visits, we will draw some blood so that we
Age: can check for the levels of the laboratory tests that are in abnormal
Gender:
Weight: range prior to her first visit.
Height:
BMI:  Decrease the consumption of iodine specially in foods high in iodine
Name: Debbie James level and check if her multivitamins contains too much iodine. If so,
Age: 32
Gender: Female advise the patient to change her vitamins with less iodine percentage.
Weight: 58 kg
Height: 5’6”  Contact your doctor or me if any unusual side effects, such as rash,
BMI: 19.9 kg/m2
(Normal) shortness of breath occur while taking the medication.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

CLINICAL COURSE FOLLOW-UP QUESTIONS SELF-STUDY ASSIGNMENTS >

The patient is started on the treatment you recommended and returns for a 1-month follow-up visit.
The following information is obtained:

Name: Vital Signs

Age: Normal Values Then Now Interpretation
Gender:
Weight: Blood Pressure <120/< 80 mmHg 130/78 124/70 mmHg Lowered

Height: 98 bpm
Pulse 60 – 100 bpm 120 – 160 bpm Lowered
BMI: Irregular

Respiratory Rate 12-16 breaths/min 20 breaths/min 16 breaths/min Lowered

Name: Debbie James
Age: 32 Temperature <37°C 38.1°C 37.2°C Lowered
Gender: Female Laboratory Results
Weight: 58 kg
Total T4 4.5-12 mcg/dL 18 mcg/dL 14.2 mcg/dL Lowered
Height: 5’6”
BMI: 19.9 kg/m2 TSH 0.35-6.20 mUI/L <0.018 mIU/L <17 mUI/L Increased
(Normal)
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

CLINICAL COURSE FOLLOW-UP QUESTIONS SELF-STUDY ASSIGNMENTS >

1. What interventions, if any, would you suggest at this point?

Basing on the current laboratory results obtained from the patient, it can be
Name:
observed that there has been an improvement in her therapy. Hence, the therapy can
Age:
Gender: be continued. However, monitoring of the thyroid hormones should be practiced to
Weight:
not drop too low which could result to hypothyroidism.
Height:
BMI:

Name: Debbie James 2. If the patient subsequently becomes hypothyroid but clinical signs indicate that
Age: 32 the patient still has Graves’ disease, what plan should be implemented?
Gender: Female
Weight: 58 kg Discontinue antithyroid therapy and administer thyroid replacement
Height: 5’6” hormone therapy to increase thyroid hormone. Co-administer beta-blocker to help
BMI: 19.9 kg/m2
(Normal) manage hyperdynamic circulatory symptoms.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

CLINICAL COURSE FOLLOW-UP QUESTIONS SELF-STUDY ASSIGNMENTS >

1. Develop a monitoring protocol for the pharmacotherapy of hyperthyroidism.

 Consider monitoring the following:

1) TSH
Name: Every 6 weeks for first 6 months
2) Free T4
Age: until TSH is normal.
3) Free T3
Gender:
Weight:
Height: 2. Design a systematic approach for a patient counseling technique for the drug therapy of
BMI: hyperthyroidism.
Tell the patient to:
Name: Debbie James  Take the medications as prescribed at the same time each day.
Age: 32  A need to change inhaler type to non-adrenergic inhaler to help manage bronchitis
Gender: Female while not exacerbating hyperdynamic circulatory state (tachycardia)
Weight: 58 kg  A selective beta 1- blocker will help manage fast heartrate while not exacerbating the
Height: 5’6” patient’s bronchitis.
BMI: 19.9 kg/m2  Make sure to return to the physician to monitor and check the levels of TSH, T 4 and T3
(Normal) every 6 weeks for the first 6 months of therapy.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

CLINICAL PEARL REFERENCES

Hyperthyroidism in pregnant women must be treated to avoid fetal

Name:
Age:
complications or death. Surgery and radioactive iodine are contraindicated in
Gender: pregnancy. PTU is preferred because it does not cross the placental barrier as
Weight:
Height: efficiently as methimazole. The lowest dose possible should be used to avoid
BMI:
fetal hypothyroidism and goiter. Free T4 levels should be used to monitor
Name: Debbie James
therapy and should be maintained within the upper limit or slightly above
Age: 32
Gender: Female normal to mimic the slightly elevated free T4 levels seen in euthyroid
Weight: 58 kg
Height: 5’6” pregnancies. TSH and free T3 levels can be misleading when used to monitor
BMI: 19.9 kg/m2
(Normal) therapy.
 Patient Record Subjective Objective Assessment Plan FAQs Hyperthyroidism

CLINICAL PEARL REFERENCES

Name:
Age:
Gender:
Weight:
Height:
BMI:

Name: Debbie James

Age: 32
Gender: Female
Weight: 58 kg
Height: 5’6”
BMI: 19.9 kg/m2
(Normal)
E-Health Subjective Objective Assessment Plan FAQs Hyperthyroidism

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