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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize the signs and symptoms of mild and overt hypothyroidism

  • Identify the goals of therapy for hypothyroidism

  • Develop an appropriate treatment and monitoring plan for thyroid replacement using individual patient characteristics

  • Select an appropriate product for thyroid replacement therapy

  • Properly educate a patient taking thyroid replacement therapy

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PATIENT PRESENTATION

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Chief Complaint

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"I'm so tired lately. I have no energy. Maybe I need some vitamins or something."

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History of Present Illness

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Yi-Ling Wang is a 49-year-old woman who presents to her new physician complaining of feeling tired, lethargic, and "not thinking straight" for the last 6 months. She has seen her previous primary care physician several times and has been told that her symptoms are probably due to anemia from menorrhagia, stress, depression, and/or impending menopause. She was not entirely satisfied with those explanations, and despite treatment with iron (and resultant improvement of her anemia), a hormonal contraceptive to help regulate her menstrual cycle, and an antidepressant, her symptoms have slowly worsened. Two years ago at a pharmacy student-run health fair, she was told her TSH was 6.2 μIU/mL (6.2 mIU/L) and her total cholesterol was 246 mg/dL (6.36 mmol/L). Y-L's primary care physician felt the TSH value was compatible with subclinical hypothyroidism and therefore could not explain her symptoms at that time. She has been wondering if she really is depressed and why the depression medication is not helping. Over the past few months, she has also noticed that her skin seems a little more dry and itchy and that she has difficulty keeping warm even in warm weather. Finally, she asks you what is good for constipation since the Chinese herbs her mother gave her are not helping.

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Past Medical History

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Iron-deficiency anemia diagnosed 6 months ago

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Depression × 6 months

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Menorrhagia diagnosed 6 months ago

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Osteopenia × 1 year

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Family History

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Father had CAD and died of gastric cancer at age 74. Mother is alive at age 70 with osteoporosis and hypothyroidism. She has one older brother who is healthy.

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Social History

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Came to the United States from China at age 15. Speaks Mandarin and English. Married and lives with her husband of 24 years; has two children, aged 22 and 19. Works as a language instructor at a local community college.

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Tobacco/Alcohol/Substance Use

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Social drinker; (−) tobacco or illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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Penicillin (rash as child)

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Medications (Current)

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MOM 30 mL PO q 24 h PRN constipation

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Rhubarb (Chinese herbal product) PO PRN constipation

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Sertraline 50 mg PO q ...

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