Hypothyroidism Case Study

Hypothyroidism Case Study

Student’s Name

Institutional Affiliation

Hypothyroidism case study

Hypothyroidism is a health condition in which the thyroid gland is underactive and thus does not produce sufficient thyroid hormone. Hyperthyroidism presents as sluggish metabolism because the thyroid hormone is not enough to control the ability of the cells in the body to use energy from food, thus affecting the proper functioning of the brain, hear, skin and muscles. The disease affects about 4% of Americans and can be classified as primary, secondary, and tertiary hypothyroidism depending of the level of thyroid-stimulating hormone (TSH) (Merson, 2018). That is about 27 million Americans with more than half of them being undiagnosed. In this respect, the American thyroid association has recommended that women of 35 years and under undergo regular screening for thyroid dysfunction every 5 years. The case of a 50-year-old Claire is used to discuss the disease, its diagnosis, symptoms, treatment and associated support interventions.

Case description

History of Present Illness (HPI)

Claire (not her real name) is a 50 year old woman who complains that in the last one year, she has added 20 pounds progressively. Consequently, she is considered as being moderately obese. As a housewife, she experiences constipation regularly, slight loss of memory, and frequent fatigue even when she has not done much physical activities. Claire has also been experiencing palpitations after minimal exertion for the last 6 months.
Previous Medical History

Claire was diagnosed with diabetes 16 years ago and is under metformin medication, which is administered orally. Moreover, 5 years ago, Claire was diagnosed with throat cancer that had developed due to heavy smoking habit and was treated successfully using a combination of chemotherapy and radiation therapy. However, there is no history of hypothyroidism in Claire’s family.  
Medication Allergies

Claire has no known allergies.  
Vital Signs

Claire’s blood pressure is 170/100 and her pulse rate is 82 beats per minute.
Physical Exam Findings

Upon physical examination, Claire had swollen face, especially around her eyes, and swollen legs. Her skin was abnormally dry and pale, and her reflexes were slower than normal for a person of her age. Moreover, her nails were unusually brittle and her hair was thinning.

Description of Disease

Pathophysiology

They pathophysiology in hypothyroidism is the reduction of the metabolic rate at rest and the collection of fluids in body tissues due to the accumulation of glycoaminoglycans deposits. In other words, a reduced basal metabolic rate and myxedema characterize hypothyroidism. The hypothalamic-pituitary-thyroid axis is a self-regulation circuit that regulates the functions of the thyroid and anterior pituitary glands and the hypothalamus. In this respect, primary hypothyroidism is associated with thyroid disorders in which triiodothyronine (T3) and thyroxine (T4) are either not produced or produced in small quantities. Secondary hypothyroidism is related to disorders of the pituitary gland, which leads to reduced thyroid-stimulation hormone (TSH) and thus the reduced levels of T3 and T4. Tertiary hypothyroidism is associated with hypothalamic dysfunctions in which the thyrotropin-releasing hormone (TRH) is reduced, which in turn, reduces the TSH and consequently the T3 and T4 levels (Rafieian-Kopaei, 2018).

Common Signs and Symptoms

The signs and symptoms of hypothyroidism are associated mainly with reduced metabolic rate and generalized myxedema. Those related to low metabolic rate include weight gain despite low appetite, dry skin, hair loss, cold intolerance, muscle cramps, bradycardia, fatigue, delayed tendon reflex relaxation, and body stiffness. Similarly, those related to generalized myxedema are hoarse voice, puffy appearance, dilated cardiomyopathy, and doughy skin texture. However, other symptoms like erectile dysfunction, decreased libido, abnormal menstrual cycles, impaired cognition, goiter, hypertension, atrophic thyroid and galactorrhea are also witnessed in some people (Dunn & Turner, 2016).

Blood tests that check the level of the thyroid-stimulation hormone (TSH) and the amount of thyroxine is used to diagnose hypothyroidism. In this case, an abnormally high level of TSH is indicative of the disease. Similarly, a thyroxine test using free T4 and free T4 index can be performed to check the functioning of the thyroid gland. Further, testing for serum anti-thyroid peroxidase antibodies (TPO), specifically, thyroid peroxidase (TPO Ab) and thyroglobulin (Tg Ab), is conducted to determine the presence of an autoimmune disorder to the thyroid gland. The normal range of TSH is between 0.4 and 4.0 milliunits per liter and therefore TSH levels above 4.0 mU/L that is accompanied by low levels of T4 are indicative of hypothyroidism. However, it the TSH levels are high but the T4 levels are normal and the anti-TPO antibodies are present, regular testing is needed to capture the onset of the disease. In addition, a radioactive iodine uptake test can be conducted to determine whether the thyroid gland absorbs at the normal range of between 10 and 35 %. Hypothyroidism is indicted by intake levels below this range.

Potential Barriers

Since Claire is a housewife, she thinks that her condition is normal because of her advancing age and inactivity as her 2 children are in college. Moreover, her symptoms are shared by several of her friends. Besides, being an African American woman, she is expected to bear minor illnesses bravely, considering that she survived the throat cancer scare 5 years ago. In this respect, she does not undergo regular medical checkups because of concerns about additional payments on her health insurance cover. 

Patient education can help increase Claire’s knowledge of her condition and improve her health-seeking behavior, especially when it is done in culturally-appropriate manner. The physician should encourage Claire to discuss her health conditions and general wellbeing to unearth any other underlying factors that by limit the effectiveness of managing her condition, considering that her medication regime may last a lifetime. Indeed, Dew et al. (2018) advocate regular and comprehensive information exchange between the patient and healthcare profession to facilitate diagnosis and development of an effective management regime to improve medication adherence.   

Medication Management

First line prescribed medication

Synthroid, which is generically known as levothyroxine sodium, is a drug made by Abbott Laboratories in the United States to treat hypothyroidism. The active compound in the medication is levothyroxine, which is an artificial version of the thyroxine hormone. The medication is administered orally at dosages prescribed by the physician. Usually, this medication is administered at about 1.7 mcg/kg/day and may be reduced to less than 1.0 mcg/kg/day for patients older than 50 years (RxList, 2020). For Claire, a dosage of 25-50 mcg/day is recommended with the dosage being increased after intervals of 6-8 weeks as she advances beyond 50 years.

Synthroid acts as a synthetic alternative to the thyroxine hormone that is produced naturally by the thyroid gland, and therefore, is used in replacement therapy. However, the drug has several side effects, including increased appetite, weight loss, insomnia, anxiety, hyperactivity, muscle weakness, tremors, and headaches. It may also cause abdominal cramps, vomiting, diarrhea, hair loss, menstrual irregularities, and reduced bone mineral density. Moreover, the inactive ingredients may cause hypersensitivity reactions in some patients, which manifest as flushing, skin rash, wheezing, serum sickness, and gastrointestinal reactions. In severe conditions, Synthroid may cause increased blood pressure, heart failure and cardiac arrest, especially in patients with cardiovascular conditions.

Contraindications of Synthroid include osteoporosis, diabetes, Addison’s disease, overactive thyroid gland, pituitary hormone deficiency, and thyrotoxicosis crisis. Besides, Synthroid interacts with certain medications and therapies, including tolbutamide, sulfonamides, propylthouracil, methimazole, amiodarone, aminoglutethimide, lithium, and iodine treatments, which may aggravate hypothyroidism.  Moreover, Claire should be checked for allergic reactions to Synthroid, which may cause myxedema coma, in which case, the intravenous administration of the drug should be considered. However, if the patient does not present any complications upon using Synthroid, its optimal therapeutic effects may be attained within 4-6 weeks.

Second line medication

Cytomel, which is generically known as Liothyronine sodium, is commonly used as a second-line drug for managing hypothyroidism. The drug acts by increasing the metabolic rate in body tissues by promoting gluconeogenesis and protein synthesis (Dayan & Panicker, 2018). It replaces triiodothyronine (T3) which is a thyroid hormone formed after the breaking down of thyronine (T4) outside the thyroid gland.

Expectations for follow-up care

Since the medications are administered over the lifetime of the patient, regular monitoring of the T3 and T4 levels is critical (Dayan & Panicker, 2018). Although the optimal results are observable after between 4 to 6 weeks, the dosage needs to be adjusted over time depending on the feedback obtained by the physician. Therefore, it is recommended that Claire undertakes tests every 2 months to ascertain her TSH level, determine drug interactions, and check for cancerous tumors, considering that she has a history of throat cancer. 

Conclusion

Claire can manage her hypothyroidism using Synthroid or Cytomel. Although these drugs are administered for a lifetime, they can regulate TSH to normal levels and improve Claire’s metabolism. However, Claire needs to adhere strictly to the medication regime to derive maximum benefits. In this regard, she should be regularly checked for TSH levels, contraindications, drug interactions and cancerous tumors to benefit fully from the medication therapy.

Questions

1. Hypothyroidism affects mostly
   1. The spleen
   2. The pituitary gland
   3. The skin
   4. The thyroid gland
   5. The blood vessels
   6. All the above
   7. None of the above
2. The best diagnosis for hypothyroidism is
   1. Checking weight
   2. Testing the blood
   3. Testing the stool
   4. Swollen thyroid glands
   5. Skin dryness
3. The recommended first line medication for hypothyroidism is
   1. Extracts from animal thyroids
   2. Serum replacement
   3. levothyroxine sodium
   4. Liothyronine sodium
   5. Blood transfusion
4. Which of the following are not one of the counterindications of hypothyroidism medication
   1. Osteoporosis
   2. Decalcification
   3. Iron deficiency
   4. Weight gain
   5. Excesses skin wetness
5. Ability to absorb medication is affected by
   1. Carbohydrates
   2. Iron supplements
   3. Calcium supplements
   4. Antacids
   5. Water

References

Dayan, C., & Panicker, V. (2018). Management of hypothyroidism with combination thyroxine (T4) and triiodothyronine (T3) hormone replacement in clinical practice: a review of suggested guidance. Thyroid Research, 11(1), 1-12. doi: 10.1186/s13044-018-0045-x.

Dew, R., King, K., Okosieme, O. E., Pearce, S. H., Donovan, G., Taylor, P. N., … & Wilkes, S. (2018). Attitudes and perceptions of health professionals towards management of hypothyroidism in general practice: a qualitative interview study. BMJ Open, 8(2), e019970. doi:10.1136/bmjopen-2017-019970.

Dunn, D., & Turner, C. (2016). Hypothyroidism in women. Nursing for Women’s Health, 20(1), 93-98. doi:10.1016/j.nwh.2015.12.002.

Merson, J. (2018). Hypothyroidism. Journal of the American Academy of Physician Assistants, 31(12), 43-44. doi:10.1097/01.jaa.0000547758.46299.d9.

Rafieian-Kopaei, M. (2018). Thyroid diseases: Pathophysiology and new hopes in treatment with medicinal plants and natural antioxidants. International Journal of Green Pharmacy (IJGP), 12(03), 1-10.

RxList (2020). Synthroid. Retrieved from https://www.rxlist.com/synthroid-drug.htm#indications.