PHL411/PL504

Assignment discussion
Hypothyroidism
 Case
Chief Complaint:
“I always feel so tired lately. Maybe I’m working too hard?”

Christina Lopez is a 45-year-old woman who presents to her new PCP complaining of feeling
tired, lethargic, and “fuzzy-headed” for the last 6 months. She has seen her previous PCP
several times over this period of time, and she has been told that her symptoms are probably
due to anemia, depression, or perimenopause. Several months ago, she developed
menorrhagia that resulted in iron defi- ciency anemia (hematocrit 31%, MCV 68 μm3).
However despite treatment with iron (and resultant improvement of her anemia), a hormonal
contraceptive to help regulate her menstrual cycle, and an antidepressant, her symptoms have
slowly worsened. She notes that 2 years ago, she attended a local health fair that provided a
variety of laboratory tests. The result of her TSH at that time was 6.2 mIU/L, and her total
cholesterol was 246 mg/dL. Her PCP felt that the TSH value was compatible with subclinical
hypothyroidism and therefore could not explain her symptoms. She also has noticed that her
skin seems more dry and itchy and that she has difficulty keeping warm and frequently wears
Case Cont’d
• PMH: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. Social drinker; (–) tobacco
or illicit drug use.
• Meds: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
Case Cont’d
• ROS: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 constipa- tion in
the past year; reports cold extremities; (–) history of seizures, syncope,
or LOC, (+) dry skin
• Physical Examination:Well-appearing, middle-aged, Hispanic woman.
Case Cont’d
• Vital Signs:BP 142/89, P 64, RR 18, T 36.4°C; Wt 68 kg, Ht 5'4''
• Skin:Dry appearing skin and scalp; (–) rashes or lesions
• (–) thyroid nodules or goiter
 Case Cont’d
• Labs: symmetric Labs
• Na 142 mEq/L Hgb 13.6 g/dL Anti-TPO antibody +
• K 4.1 mEq/L Hct 40.1% TSH 12.8 mIU/L
• Cl 100 mEq/L WBC 7.6 × 103/mm3 Free T4 0.71 ng/dL
• CO2 24 mEq/L MCV 83 μm3 T. chol 268 mg/dL
• BUN 9 mg/dL Ca 9.4 mg/dL LDL chol 142 mg/dL
• SCr 0.8 mg/dL Mg 1.8 mEq/L HDL chol 36 mg/dL
• Glu 104 mg/dL PO4 3.8 mg/dL
• Albumin 3.8 g/dL
• AST 22 IU/L
• ALT 19 IU/L
• T. bili 0.4 mg/dL
• Alk phos 54 IU/L
• Assessment
• 45-year-old woman with signs, symptoms, and laboratory tests consistent with hypothyroidism
QUESTIONS:
1. What information (signs, symptoms, laboratory values) indicates the
presence of hypothyroidism?
2. List examples of medications that are known to cause hypothyroidism.
3.Could any of the patient’s complaints have been caused by drug therapy?
4.What are the goals of pharmacotherapy for this patient?
5. What nondrug therapies might be useful for this patient?
6. What feasible pharmacotherapeutic alternatives (including
complementary/alternative medicine products) are available for treatment of
hypothyroidism?
7. What clinical and laboratory parameters are necessary to evaluate thyroid
replacement therapy to achieve euthyroidism and prevent adverse effects