Case Study: A 42-year-old female complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-year-old daughter and has been attempting to have another child with her new partner. She has been unsuccessful.

Physical Assessment

Case Study: A 42-year-old female complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-year-old daughter and has been attempting to have another child with her new partner. She has been unsuccessful.

Questions:

1. What is the client’s chief complaint?

The patient complains of a progressive increase in weight for one year, tiredness, postural dizziness, amnesia, slowed speech, deepening of voice, skin turning dry, constipation, and intolerance to cold. The patient reports having been experiencing irregular menses for one year. She says she unsuccessfully had another child with her new partner despite numerous attempts for the same. She reports having a daughter aged 18 years old.

2. What questions would you ask the client?
   • HPI (history of present illness)

• Have you noticed any swelling on your neck? For how long have you noticed it?
• Do you experience any pain when swallowing food?
• Has there been a change in your appetite and weight?
• Which environment do you prefer staying? Hot or cold?
• Have you had any diarrhea or constipation?
• Do you normally experience tremors?
• Do you feel irritable, nervous, or anxious sometimes?
• Do you have any symptoms of depression like sadness, loss of interest in activities, feeling guilt, and hopelessness?
• Do you have a history of radioiodine therapy?
• Have you noticed any changes in your voice, like hoarseness?
• Have you detected brittle hair or nails?

(Wilson et al., 2021)

• ROS (review of systems)

• Cardiovascular system: Do you experience awareness of heartbeat? Have you experienced paroxysmal nocturnal dyspnea, orthopnea, or shortness of breath?
• Respiratory system: Do you have a history of dyspnea?
• Musculoskeletal system: Do you have a history of bone pain, especially in the wrist joint?
• Gastrointestinal system: Do you have changes in your weight and appetite?
• Hematologic system: Do you have bleeding diathesis, weakness, and fatigue?
• Reproductive system: Are you active in sex? How are your periods?

(Ross, 2023)

• Medical/Surgical/Psych History: Have you ever been diagnosed with any thyroid disease? Have you ever had a thyroidectomy? Are you on any prescribed antithyroid medications? Have you ever been on lithium or amiodarone? Any exposure to radioiodine? Have you been diagnosed with any psychiatric illness?
• Family History: Do you have a family member with similar complaints? Do you have a history of thyroid cancer in your family?
• Other: None.
  

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3. What physical examinations would you include?

Body System	Include? ü (yes) or – (not indicated)	Notes
General survey	ü	The general physique of the patient, any body asymmetry, nutritional status, any swelling on the neck, the appearance of the face, head, and hairs, any tremors.
HEENT (head, eyes, ears, nose, throat/thyroid)	ü	Inspection of the neck for thyroid enlargement, asking the patient to swallow saliva and observe thyroid movement, asking the patient to protrude tongue to observe thyroid/movement of the mass, palpating the thyroid gland for mobility, tenderness, shape, regularity, skin changes, fixity, measuring its size, and auscultating the mass for bruits. Observe the eyes for ophthalmoplegia and lid lag signs. Ask for dysphagia and odynophagia.
Cardiovascular	ü	Count the pulse rate, observe the precordium if it is hyperactive, auscultate heart sounds, and auscultate for any crackles suggestive of pericardial effusion. The stethoscope should be placed on the actual skin.
Peripheral Vascular	Not indicated
Breasts	ü	For galactorrhea.
Lymphatic	Not indicated.
Pulmonary	ü	Auscultate lung sounds (stethoscope to actual skin) – anterior and posterior
Gastrointestinal/Abdominal	ü	Auscultation of bowel sounds, any abdominal distension, and tenderness, and to rule out ileus.
Genitourinary/Pregnancy	ü	Pregnancy test, urinary frequency.
Integumentary	ü	If the skin is dry, any vitiligo, any erythematous appearance, and alopecia on the head.
Musculoskeletal	ü	For carpal tunnel syndrome, bone pain, and muscle pain.
Neurological	ü	For deep tendon reflexes.

(Chiovato et al., 2019)

4. What are pertinent positive physical assessment findings?

• Enlargement of the thyroid gland
• Dry skin
• Palmar and conjunctival pallor
• Peripheral edema
• Thin and brittle hair
• Periorbital puffiness
• Dry skin
• Bradycardia
• Delayed relaxation phase of the deep tendon reflexes.

(Wilson et al., 2021)

5. What are the pertinent negative physical assessment findings?

• No palpitations
• No tremors
• No sweating
• No loss of weight
• No shortness of breath
• No exophthalmos

6. What are at least 3 differential diagnoses (use Up-to-Date App if needed)?
   • Primary hypothyroidism
   • Secondary hypothyroidism
   • Hashimoto’s thyroiditis (Autoimmune thyroid disease)

(Ross, 2023)

7. What is your primary diagnosis?

Primary hypothyroidism (Wilson et al., 2021).

8. What is your treatment plan?
   • Diagnostic procedures

• Fine needle aspiration cytology (FNA). This involves aspirating a sample from the thyroid mass that will be investigated to diagnose goiter causing hypothyroidism and rule out the mass being a tumor.
• Magnetic Resonance Imaging (MRI) enhanced with gadolinium to detect the presence of any mass.
• Chest X-ray and electrocardiogram as part of evaluation for heart failure.
  • Labs
• Thyroid function tests to check for levels of thyroid stimulating hormone (TSH), serum T3, and serum T4. In primary hypothyroidism, the levels of TSH are high, while serum T3 and T4 are low (Wilson et al., 2021).
• Complete blood count to check for hemoglobin levels since the patient would be anemic. The hematological manifestation of hypothyroidism is anemia (normocytic normochromic anemia) (Wilson et al., 2021).
• Lipid profile may show hyperlipidemia, liver function tests may show elevated hepatic enzymes, and there might be elevated serum CK (Patil et al., 2022).
  • Client Education

The patient needs to be aware that she will be on thyroid medications for some time to raise her thyroid hormones which are essential for metabolic activities. She should be advised to be compliant with her medications and adhere to time when she is supposed to take them. Regarding her reproductivity, she should be advised to try to conceive after starting her therapy for hypothyroidism. The patient should be informed of signs to watch out for just in case the thyroid replacement therapy results in hyperthyroidism. Reporting in time will help the clinician to adjust her levothyroxine dose effectively.

• Pharmacotherapy

Treatment of hypothyroidism is through drugs that increase the amount of thyroid hormone in circulation. There are various thyroid hormone preparations that are available for replacement therapy. They include levothyroxine, which is a synthetic preparation of T4, liothyronine, a synthetic preparation of T3, or a combination of the two products (Patil et al., 2022). The preferred replacement therapy is levothyroxine with a maintenance dose of 75 to 150 mcg taken orally once a day (Patil et al., 2022). The patient should be evaluated for heart disease and if present, the dose should be adjusted to lower doses of 25mcg once a day.

• Health Promotion

Among the causes of hypothyroidism is iodine deficiency (Patil et al., 2022). As part of the promotion of the patient’s health, she should be advised to check her diet and take foods with enough iodine. Patients with hypothyroidism are at risk of developing congestive heart failure and other neuropsychiatric illnesses, such as depression (Patil et al., 2022). The patient is also worried that she has not got another child with her new partner despite attempting to. This may precipitate depression. Therefore, it will be appropriate to have a multidisciplinary involvement in the care of the patient, with endocrinologists, cardiologists, surgeons, and psychiatrists coming in hand to help.

• Follow-Up

Return to the clinic after four weeks.

References

Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in Context: Where We’ve Been and Where We’re Going. Advances in Therapy, 36(Suppl 2), 47–58. https://doi.org/10.1007/s12325-019-01080-8

Patil, N., Rehman, A., & Jialal, I. (2022). Hypothyroidism. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK519536/

Ross, D. (2023, May 30). UpToDate. Www.uptodate.com. https://www.uptodate.com/contents/treatment-of-primary-hypothyroidism-in-adults#

Wilson, S. A., Stem, L. A., & Bruehlman, R. D. (2021). Hypothyroidism: Diagnosis and Treatment. American Family Physician, 103(10), 605–613. https://www.aafp.org/pubs/afp/issues/2021/0515/p605.html

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Case 1: A 42-year-old female complains of progressive weight gain of 20 pounds over the last year, fatigue, postural dizziness, loss of memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance. She claims her menses have been irregular x 1 year. She has an 18-year-old daughter, and has been attempting to have another child with her new partner. She has been unsuccessful.