What additional subjective and objective assessments should be included in the patient examination?

Subjective assessment: Detailed menstrual history such as duration, frequency, and severity of her menstrual periods. History of weight gain, asking about her current diet and exercise regimen, any recent changes, and if she has tried to lose weight without success. Inquire about the quality and duration of her sleep, any recent changes in her energy levels, and if she experiences daytime sleepiness. Any previous evaluation and treatment for difficulty getting pregnant. Gathering information about any previous diagnosis or treatment, such as hormonal testing or fertility treatments, and the outcome. Asked more about her family history of thyroid problems such as specific information if possible, such as the type of thyroid disorder and any treatment received.

Objective assessment: Vita signs should be obtained, measuring the patient’s blood pressure, heart rate, respiratory rate, and temperature. General appearance, observing the patient for any signs of distress, cachexia or abnormal body habitus. Palpate the neck for thyroid gland for any enlargement or nodules. Check for any signs of distention or tenderness of the abdominal examination that could suggest the presence of a mass or other abdominal pathology. Perform a pelvic examination to assess the size, shape, and consistency of the uterus and ovaries. Look for any abnormal findings such as masses or tenderness. 

Explain whether this patient should have had a routine screening of thyroid function prior to today’s visit.

Based on the information provided, it is difficult to determine whether the patient should have had routine screening of thyroid function prior to today’s visit. However, her symptoms of sudden weight gain, fatigue, and heavy menses can be indicative of a thyroid disorder, particularly hypothyroidism. Additionally, her family history of thyroid problems, although lacking specific information, raises further suspicion. Routine screening for thyroid function, such as measuring thyroid-stimulating hormones (TSH) levels, is not typically performed in asymptomatic individuals without risk factors or concerning symptoms. However, in this case, the patient’s symptoms and family history may warrant consideration for thyroid function testing (Chaker et al., 2019).

Which testing is needed to diagnose hypothyroidism?

To diagnose hypothyroidism, various tests are generally conducted. The most common test is the thyroid-stimulating hormone (TSH) test, which determines if the thyroid gland is functioning properly based on elevated TSH levels. The Free thyroxine (FT4) test measures the levels of a hormone crucial for metabolism regulation and is often low in hypothyroidism. The thyroid peroxidase antibody (TPOAb) test detects antibodies that attack the thyroid gland, often associated with autoimmune thyroid diseases like Hashimoto’s thyroiditis. Additional tests, such as the Total or free triiodothyronine (T3) test and thyroid ultrasound, may be used to investigate underlying causes and assess thyroid health (Chaker et al., 2019). 

Why is the measurement of free T4 always preferred over the total T4?

The measurement of free T4 is generally preferred over total T4 because free T4 is the biologically active form of the hormone that is available for use by cells in the body. Total T4, however, includes both free T4 and T4 bound to proteins in the blood. While bound T4 can act as a reservoir, it is not readily available for use by cells. By measuring free T4, we can obtain a more accurate representation of the level of active thyroid hormone in the body, which aids in diagnosing and monitoring thyroid disorders. Free T4 levels can directly reflect the thyroid gland’s function and provide a better assessment of the hormonal status. Therefore, it is considered a more reliable indicator of thyroid function compared to total T4 (Bosma, Du Puy & Ballieux, 2022).

Under what circumstances should this patient be referred to an endocrinologist for treatment?

Patients with hypothyroidism should be referred to an endocrinologist for treatment in several circumstances. These include severe hypothyroidism symptoms, treatment resistance, pregnancy, presence of other health, and suboptimal response to initial treatment. An endocrinologist can provide specialized care, monitor hormones levels, adjust medications, and coordinate treatments plans (Chaker et al., 2019).

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