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Chief Complaint

“I have been feeling more tired lately”

History of Present Illness

HT is a 71-year-old woman with a history of atrial fibrillation and stage 1 hypertension who presents with a 1 month history of increasing fatigue. She wonders if she might be depressed or if she has low blood from the Eliquis she takes. Diagnostic workup shows a normal CBC and an elevated TSH and slightly low free T4 level. Her anti-thyroid peroxidase (anti-TPO) antibody test is positive.

Student Work-Up

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Missing Information?


Patient Database

Drug Therapy Problems

Care Plan (by Problem)


  1. What signs and symptoms of hypothyroidism does the patient have?

    Hint: See Hypothyroidism in PPP

  2. What is the likely cause of hypothyroidism in this patient?

    Hint: See Hypothyroidism in PPP

  3. What are the indications for initiating levothyroxine replacement therapy?

    Hint: See Hypothyroidism in PPP

  4. How does the patient’s age and history of atrial fibrillation impact on your management of her hypothyroidism?

    Hint: See Hypothyroidism and Hyperthyroidism and Thyrotoxicosis in PPP

  5. What risks and adverse effects of therapy would you discuss with the patient?

    Hint: See Hypothyroidism in PPP


The patient comes back to see you three months later, and she is feeling much better. She has noticed that each time she has her levothyroxine refilled, the tablets look different. She asks if this is a problem. How would you respond?

Hint: See Hypothyroidism in PPP


Global Perspective

Goiter, an enlargement of the thyroid gland, is caused by a variety of conditions, and can be associated with normal, excessive, or deficient thyroid function (Fig. 51-1). The worldwide prevalence of goiter is estimated to be 15.8%, with 4.7% in the U.S and 28.3% in Africa. In developed countries, enlargement of the thyroid gland is most often associated with nodular goiter, autoimmune thyroiditis, and Grave’s disease. However, in developing countries, iodine-deficient diet is commonly associated with goiter, though there have been improvements in iodine intake in many countries, particularly in Europe, Asia and the Western Pacific with less improvement in iodine intake in African countries. Iodine deficiency and endemic goiter are especially common in women of childbearing age since pregnancy increases iodine requirements. Substances in the diet can also serve as goitrogens. Diets high in foods or herbal products containing cyanoglucosides (cassava, lima beans, maize, bamboo shoots, and sweet potatoes) release cyanide, which is then metabolized to thiocyanate, an agent that inhibits iodine transport. Foods or herbal products high in thioglucosides (cruciferous vegetables) can have a thionamide-like effect on the thyroid gland. Endemic goiter ...

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