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Michelar: Week 6: Clinical Case Study Part 2 Primary Diagnosis My Primary diagnosis will be Primary Hypothyroidism. Positives Findings- Fatigue, weight gain of 5lbs, constipation, cold intolerance, dry skin, muscle cramps, feeling depressed, DTR’s 2+. Lab Findings: TSH 6.770 uIU/mL; FT4 0.62 ng/dL Negatives Findings- Denies family history of thyroid disorder. ICD-10 code: E03.9 Treatment Plan Medication According to Chaker et al (2017), the drug of choice to treat hypothyroidism is Levothyroxine 1.5-1.8 mcg/kg/day in patients without comorbidities and 12.5 to 25mccg/day for patients 50years and older and those with cardiac disease. Based on the patients age and history of Hypertension, I will start her at the lower dose and titrate up every 4-6 weeks as needed to achieve euthyroid. Prescription Levothyroxine 12.5mcg po Dispense # 30 Sig: 1 tab daily in the mornings before meals and other medications Number of refills: 0 Additional Testing A Thyroid Peroxidase antibody test can be done which would be useful in affirming the diagnosis of hypothyroidism and any autoimmune relationship (Chaker et al, 2017). Vitamin C level Vitamin D level Patient education Take medication only as prescribed/ do no switch brands. Take medication on an empty stomach 30-45minutes before breakfast or at least 3hrs after evening meal to increase absorption and effectiveness of medication (Patiel et al, 2020) Do not take Levothyroxine with 4 hours of taking your Vitamin C or D supplements, this may decrease absorption. It may take several weeks before you notice any improvement in symptoms. Notify your dentist or other physicians that you are taking levothyroxine prior to any procedure or surgery. Call 911 or your Provider if you are experiencing palpitations, chest pain, shortness of breath, headache, leg cramps, diarrhea, heat intolerance, fever, rash/hives, vomiting. You may lose some hair during the first few months of treatment which is usually temporary. (Prescriber Digital Reference, 2020) Referral No referrals will be needed at this time, patient with hypothyroidism can be managed in a Primary Care Office. If symptoms worsen, patient should be referred to an Endocrinologist (Patiel et al, 2020) Active problem list Hypertension Depression Post-Menopausal Changes to patients plan. Based on the patients age and history of HTN, changes in medication titration may be warranted to achieve a euthyroid state based on repeat TSH levels (Chaker et al, 2017). Also Hold Vitamin C/Vitamin D and order a vitamin C and D level to determine if patient will need to take these medications based on drug interaction with Levothyroxine. Appropriate F/U plan Follow up in 4 weeks, for repeat TSH and possible drug titration (Chaker et al, 2017).
