CASE STUDY 1
ENDOCRINE DISORDER: HYPOTHYROIDISM
Scenario
You are working in a community outpatient clinic where you perform the
intake assessment on R.M., a 38-year-old woman who is attending graduate
school and is very sedentary. Her chief complaint is overwhelming fatigue that is
not relieved by rest. She is so exhausted that she has difficulty walking to classes
and trouble concentrating when studying. She reports a recent weight gain of 15
pounds (7 kg) over 2 months without clear changes in her dietary habits. Her face
looks puffy, she has experienced excessive hair loss, and her skin is dry and pale.
She complains of generalized body aches and pains with frequent muscle cramps
and constipation. You notice she is dressed inappropriately warm for the weather.
Chart View
Vital Signs
Blood pressure 142/84 mm Hg
Heart rate 52 beats/min
Respiratory rate 12 breaths/min
Temperature 96.8 ° F (36 ° C)
1. Compare her VS with those of a healthy person at her same age.
VITAL SIGNS NORMAL VITAL RM’S VITAL SIGNS
SIGNS
Blood Pressure 120/80 mm Hg 142/84 mm Hg
Heart Rate 80-100 52 beats/min
Respiratory Rate 12-20 12 breaths/min
Temperature 96.8 ° F (36 ° C) -99.5 ° F 96.8 ° F (36 ° C)
(37 ° C)
2. List eight general questions you might ask R.M. to assist in determining what is
going on with her.
1) When did you notice your symptoms started?
2) Do you have any medical history I should be aware of?
3) What have your sleeping patterns been like?
4) What physical activities do you do?
5) Does anyone in your family have thyroid disease?
6) What is your typical diet?
7) What medications do you take?
8) Have your menstrual cycles changed?
3. You know that potential causes for some of R.M.'s symptoms include depression,
hypothyroidism, anemia, cardiac disease, fluid and electrolyte imbalance, and
allergies. As part of your screening procedures, describe how you would begin to
investigate which of these conditions probably do not account for R.M.'s symptoms.
As part of the screening procedures, I will begin with auscultation of the
heart and lung sounds for the sign and symptoms of cardiac problem. However,
there are no abnormalities present with RM’s heart and according to her
symptoms, it is clear that she does not have any signs of cardiac disease,
symptoms of allergies, and fluid and electrolyte imbalance. RM has symptoms of
depression, hypothyroidism, and anemia.
4. Unnecessary diagnostic tests are expensive. What tests do you think would be the
most appropriate for R.M., and why?
I think T4 or thyroxine and pituitary thyroid stimulating hormone or TSH
will be appropriate for RM because this test will conform the diagnosis of thyroid
failure. Cholesterol levels need to be checked and also other blood tests needs to
be performed to detect levels of calcitonin, calcium, prolactin, and thyroglobulin
and check for the anemia and liver function. All these tests can be affected by
hypothyroidism.
Chart View
Laboratory Test Results
TSH 20.9 mU/L (2-10 mU/L)
TRH 18.8 ng/dL (2-10 ng/dL)
T 3 24 mU/L (70-205 ng/dL)
Free T 4 0.2 ng/dL (0.8-2.4 ng/dL)
5. Interpret R.M.'s laboratory results.
6. LABORATORY NORMAL RESULTS
Thyroid Stimulating 2-10 mU/L 20.9 mU/L Increases
Hormone (TSH)
Thyrotropin-releasing 2-10 ng/dL 18.8 ng/dL increases
hormone (TRH)
Triiodothyronine (T₃) 70-205 ng/dL 24 mU/L Decreases
Thyroxine, free (FT₄): 0.8 to 2.4 ng/dL 0.2 ng/dL decreases
The family practitioner affirms a diagnosis of hypothyroidism. With this diagnosis,
what other signs and symptoms would you want to investigate?
Other signs and symptoms that I want to investigate about RM’s frequent
muscle cramps and constipation. I also notice she is dressed inappropriately warm
for the weather.
7. The family practitioner prescribes levothyroxine (Synthroid) 1.7 mcg/kg body
weight/day. At this time, R.M. weighs 130 pounds. What should be her daily dose of
levothyroxine in milligrams? How would her prescription read?
SOLUTION: 0.0017*59= 0.1003
ANSWER: 0.1 mg of levothyroxine (synthroid)
8. Why would you want to obtain a complete drug history on R.M.?
A complete drug history is essential for any patient that is starting a new drug
because not all drugs interact well with each other. I would also ask about any
herbal remedies, vitamins, and over the counter medications.
9. What general teaching issues will you address with R.M. in regard to
hypothyroidism?
Hypothyroidism occurs when the thyroid gland fails to produce and release
enough thyroid hormone into the bloodstream. This may lead to weakness or
tiredness, sluggishness, weight gain, cold intolerance, constipation, cool skin,
slowing down of the CNS system
10. What teaching needs will you review with R.M. in regards to her medication?
Take one pill everyday at the same time everyday. It should be 30 to 60
minutes before mealtime. If you missed a dose take it as soon as you remember
unless it is close to the next dose time.
11. R.M. wonders whether she should take iodine supplements if she decreases her
salt intake. She recognizes that salt is a significant source of iodine in her part of the
country. What would you explain to her?
Living in the United states you normally do not need iodine supplements.
The reason for this is due to the fact that iodine has been added to salt and is also
added to other foods.
12. What should you teach R.M. regarding prevention of myxedema coma?
Educate RM to take prescribed medication at the same time every day. Also
teach her to avoid stressful situations such as infections, trauma, or exposure.
Myxedema is an extreme complication of hypothyroidism exhibiting mental
deterioration.
13. Before R.M. leaves the clinic, she asks how she will know whether the medication
is “doing its job.” Outline simple expected outcomes for R.M.
Some expected outcomes is R.M is gradually increasing her exercise and has
higher tolerance over the next 2 months. The patient will normal bowel
movement, maintain normal body temperature, and a decrease in weight. Will
also note improved mental function, improved skin function, and a decrease in
skin dryness.
14. Several weeks later, R.M. calls the clinic stating she can't remember whether she
took her thyroid medication. What additional data should you obtain, and how would
you advise her?
Forgetting to take the medication can lead to several complications such as
fatigue, depression, myxedema coma, low temperature. Suggest the patient in
placing an alarm to not forget to take her medication at the same time everyday.
CASE STUDY OUTCOME
R.M. comes in 2 months later for a follow-up visit. You can't believe she is the same
person. She looks and walks as if she were 10 years younger. Her skin appears more
radiant, and her hair looks much healthier. “You can't believe how different I'm
feeling,” she says. “I didn't know how bad off I was; I'm starting to live again.”
