This is a 53-year-old female who presents to the clinic with wishes to discuss some recent lab work that she had done at a local laboratory.
Subjective: This is a 53-year-old female that presents with a concern wanting to discuss recent lab work she had done at â€œAny lab test nowâ€ She reports wishing to have lab work done because she was feeling increasingly tired and unmotivated. She additionally reports that she has put on roughly 15 pounds. She reports teaching yoga 2-3 times a week for the past few years. Her last menstrual period was 3 years ago, she reports some menopausal symptoms such as hot flashes and night sweats. But she reports these symptoms didnâ€™t cause too much of a problem and the symptoms resolved a couple of years ago. She denies and issues swallowing, doesnâ€™t report any neck pain or tenderness.
Constitutional exam: 5â€™5â€ tall, 154 pounds, BP 145/88, P 60, R 16, Temp 97.2
Lab Values: TSH of 93.
HEENT: nontender, mild goiter with right side of thyroid larger than the left side.
Cardiovascular: regular rhythm without murmur or gallop.
Respiratory: Lung sounds clear.
Integumentary: skin dry on extremities with some flaking noted.
Musculoskeletal: A slowness of the relaxation phase of the Achilles tendon reflex is noted.
Assessment: This patient is presenting with signs and symptoms of hypothyroidism. Her elevated TSH levels indicate her thyroid is underactive. With her symptoms of lethargy, and her menopausal symptoms of heat intolerance and night sweats, as well as her physical assessment this leads to diagnosis of hypothyroidism.
Plan: The plan for this patient will be to initiate Synthroid therapy. The goals of therapy are to restore the body to have a normal TSH laboratory value, improve the patientâ€™s signs and symptoms and decrease any chances of complications. (Arcangelo et al.,2021)
Therapeutics: This patient should be started on daily Synthroid. Her starting dosage should be 100mcg and she may titrate to maintenance 1.6mcg/kg which would mean she would need to roughly titrate up 12mg following her initial start of Synthroid (Eghtedari & Correa, 2022). Once starting Synthroid she should remain at her 100mcg dose for 6-8 and follow up to have TSH and T4 levels drawn prior to increasing dosage. Should she need to increase she may increase her dose up to 10-20% based on the TSH lab draw in order to achieve euthyroid state (Arcangelo et al.,2021).
Educational: The patient should be educated to go to follow up for lab draws and a focused wellness check regarding her symptoms. She should be educated that her symptoms can improve within a week to two weeks of initiation of therapy, however TSH levels will not change until roughly the six-to-eight-week mark of continual therapy. This patient should be educated on the severe adverse effects that can occur with Synthroid therapy. Side effects can consist of feelings of anxiety, weight loss, heat intolerance, headache, and excessive sweating. Adverse reactions can be tachycardia with palpitations and chest pain (Eghtedari & Correa, 2022). Patients may also experience atrial fibrillation, changes in mentation, and with chronic use can develop fractures as well as osteoporosis (Arcangelo et al.,2021). This patient should be advised to refrain from taking antacids, as well as medications such as sertraline, rifampin, phenobarbital, cholestyramine, kayexalate, and simethicone. She should be advised to immediately report symptoms of chest pain, palpitations, or hypertension, as dosing may need to be decreased, or discontinued in severe situations. (Arcangelo et al.,2021).
Consultation/Collaboration: No additional collaboration or consultation necessary currently.