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

Subjective– Ask about symptoms such as dry skin, cold intolerance, bowel habits, headaches, or muscle weakness are all signs of hypothyroidism (Dunphy et al., 2022). Late forms of hypothyroidism that should be assessed include coarse hair, alopecia, and hypersomnia (Dunphy et al., 2022). It is also important to ask if there is any noticeable swelling in the neck, previous radiation to the neck, or a family history of thyroid concerns.

Objective– A full assessment including vital signs and weight should be done and compared to previous encounters. The provider should look at the hair to determine if it is coarser or if there are any areas of thinning/hair loss (Dunphy et al., 2022). The provider should assess for a goiter and complete a neck exam, feeling the thyroid and checking for enlargement or tenderness (Dunphy et al., 2022). Examining the skin to assess for periorbital swelling or facial puffiness as well as looking at the skin for dryness (Dunphy et al., 2022). It is important to assess these body systems.

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

Yes, the patient should get routine thyroid screening today. She has symptoms that are consistent with hypothyroidism including unexpected weight gain, fatigue, depression, and heavy menses (Dunphy et al., 2022). Getting testing for thyroid function can help to rule out or confirm a diagnosis of hypothyroidism and should be performed based on her symptoms.

Which testing is needed to diagnose hypothyroidism?

In order to test for hypothyroidism a TSH and FT4 level should be tested (Dunphy et al., 2022). Based on the results of each test it can help determine which area of the thyroid is affected. In addition to this a T3 or T4 level can be tested if the TSH or FT4 are abnormal (Dunphy et al., 2022).

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

Total T4 is attached to protein and is transported amongst the body which can create a large change in the T4 levels (Dunphy et al., 2022). Free T4 represents less than 1% of our thyroid hormones and is the part that interacts with the cells to create cell function and is a specific representation of the thyroid function (Ettleson & Bianco, 2020).

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

If a patient is diagnosed with hypothyroidism, it is important to replace the hormone in the body with medication such as levothyroxine. It is important that the provider monitors thyroid levels and ensures the patient does not have thyroidtoxicity. If a patient is exhibiting signs of thyroidtoxicity or the patient has a diagnosis of cardiac disease, myxedema, or central hypothyroidism it is likely that a referral to endocrinology is appropriate (Dunphy et al., 2022). Closely monitoring thyroid function is very important.


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