CASE LEARNING OBJECTIVES
Recognize the signs and symptoms of subclinical and overt hyperthyroidism
Identify the goals of treatment for hyperthyroidism
Develop an appropriate pharmacotherapy care plan for the management of hyperthyroidism based on individual patient characteristics and appropriate clinical judgment
Properly educate a patient being treated for hyperthyroidism
"My neck is swollen and I am having a hard time swallowing!"
History of Present Illness
Michael Vera is a 60-year-old female who presents to the clinic complaining of swelling and tenderness in her neck with difficulties swallowing solids and liquids, as well as 5 days of watery diarrhea. She appears anxious and is having a hard time sitting still during the interview. She explains that she has not felt like herself in well over a year, but things have gotten significantly worse over the last 4 months. She has had an unintentional weight loss of approximately 70 lb (32 kg) over the past year despite an increase in appetite. She attributes this weight loss to be the reason she is so exhausted and why her muscles have felt so weak of late. She also complains that she is heat intolerant and perspires with very little activity. Finally, she inquires about allergy eye drops as her eyes have been bothering her for the last several months since they are so itchy and watery, "feeling as if they are ready to pop out of my head."
Systolic hypertension × 1 year
Atrial fibrillation × 6 months
s/p total abdominal hysterectomy/bilateral salpingo-oophorectomy (TAH/BSO) at age 45
Maternal grandmother with goiter and subsequent thyroidectomy. Mother with hyperthyroidism (treated with medication) and osteoporosis. Father with coronary artery disease and type 2 diabetes mellitus.
Married and lives with her husband of 37 years; has two dogs, and no children. She works as a kindergarten teacher at the local elementary school.
(+) Tobacco 45-pack year history (currently 1.5 ppd); (−) alcohol or illicit drug use.
Allergies/Intolerances/Adverse Drug Events
Loratadine 10 mg PO daily PRN
Verapamil 240 mg PO daily
Digoxin 0.125 mg PO daily
Calcium citrate with D (315 mg calcium with 200 IU Vitamin D3) two tablets PO three times daily
Denies chest pain, shortness or breath, abdominal pain, hematochezia, dysuria, hematuria, changes in urinary frequency or urgency.