Hypothyroidism

            Location: Office

·          Vitals:

·           Her temperature is 36.1 C (97 F), blood pressure is 150/90 mm Hg, pulse is 50/min and respirations are 16/min. She weighs 105 kg (231.5 lbs) and is 162.5 cm (5'4") tall.

·          HPI:

·          A 53-year-old African-American woman comes to the physician because of fatigue, constipation, cold intolerance, and impaired sleep. She has had these symptoms for the past three months. The symptoms are progressively getting worse. She also says that she gained almost 20 lbs of weight during the past three to four months.  

1.        Complete physical exam.

2.       look for

3.       patient appears to be obese. Skin is cool and dry.Neurologic examination shows delayed relaxation of ankle reflexes. The rest of the exam is normal.

4.       CBC, routine normochromic normocytic anemia

5.       BMP, routine Na of 133 mEq/DL

6.       FOBT, stat FOBT is negative.

7.       Serum TSH, routine ; TSH is 24 µU/mL

8.       12-lead EKG, stat shows sinus bradycardia.

9.       *Schedule appointment in three days with result 

10.    Results:

11.    *If the patient is floridly hypothyroid – TSH should be higher than 70-90.

12.     Free T4, routine

13.     Lipid panel, routine

14.     Levothyroxine, oral, continuousLow-fat diet

15.    Vitamin D, oral continuous if hypocalcemia

16.    Calcium carbonate, oral, continuous if hypocalcemia

17.    Counseling:

18.     Patient counseling

19.    Medication compliance

20.     No smoking

21.    No alcohol

22.    Regular exercise

23.    Seat belt use

24.    Safe sex

25.    *Follow-up in one week

26.    Results:

27.    Free T4 is 0.03 ng/dL (Normal is 0.9-2.4 ng/dL). The lipid panel showed increased total cholesterol. 

28.    *Follow-up in six weeks 

29.    Order:

30.    Serum TSH, routine

31.    Primary diagnosis:

32.    Primary hypothyroidism

Dr. Soryal,George