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:
- What additional findings on the physical exam would you look for?
- What implication does the previous TSH level have?
- What therapy would you institute?
- If VG becomes pregnant, what adjustment, if any, would be needed in her thyroid medication?
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.
Expert Solution Preview
Introduction:
The presented case report is about a 31-year-old female, VG, who is experiencing excessive fatigue, difficulty concentrating, and unexplained weight gain over the last month. Furthermore, VG’s periods have become irregular and heavier than usual. The blood work results show an increased TSH level of 9.8 mIL/L and a free T4 level of 0.72 ng/dL. In this scenario, as a medical professor, I would address the following questions:
1. What additional findings on the physical exam would you look for?
During the physical examination of VG, I would look for the following additional findings:
– Eyelid retraction or lag
– Tremor
– Enlarged thyroid gland
– Skin changes (e.g., dry skin, puffiness, or pallor)
– Alopecia
These additional physical exam findings would help to confirm the diagnosis of hypothyroidism.
2. What implication does the previous TSH level have?
The previous TSH level of 4.2 mIL/L, although only slightly elevated, indicates that VG had hypothyroidism, which was not diagnosed at that time. The current TSH level of 9.8 mIL/L confirms the diagnosis of hypothyroidism and indicates that it has progressed further.
3. What therapy would you institute?
Thyroid hormone replacement therapy would be the best approach to treat VG’s hypothyroidism. Levothyroxine is the preferred medication, which should be started at a low dose and gradually increased over a few weeks to achieve a stable TSH level. The dosage of levothyroxine is usually 1.6 mcg/kg/day, and it should be taken on an empty stomach in the morning at least 30 minutes before breakfast. VG should also avoid taking iron supplements and calcium-containing products simultaneously with thyroid hormone replacement because they can interfere with its absorption.
4. If VG becomes pregnant, what adjustment, if any, would be needed in her thyroid medication?
If VG becomes pregnant, her thyroid hormone replacement therapy dosage may need to be increased. During pregnancy, the thyroid hormone requirements increase due to the increased metabolic needs of both the mother and the developing fetus. The American Thyroid Association recommends keeping the TSH level between 0.1 and 2.5 mIU/L in the first trimester and between 0.2 and 3.0 mIU/L in the second and third trimesters. Therefore, it is essential to monitor VG’s thyroid hormone levels throughout her pregnancy and adjust her medication accordingly.
Conclusion:
Hypothyroidism is a common but treatable disorder. In the presented case report, VG’s hypothyroidism was not diagnosed earlier, but it has now progressed further. The medical therapy of choice is thyroid hormone replacement, and the dosage should be adjusted according to the patient’s TSH level and clinical response. During pregnancy, the dosage may need to be increased to maintain a stable TSH level.
