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Course # 38503 • Thyroid Dysfunction

CASE STUDY

Patient W arrived for her regular yearly physical exam. She is 60 years of age and has always been healthy and active. Patient W caught the attention of Nurse S because she was wearing a turtleneck sweater, slacks, and a light jacket, even though it was a sunny and warm day. When Nurse S asked how the patient was feeling, the answer was, "I've been trying hard to diet, but I still gained 12 pounds this past year. Maybe it's that I'm not exercising as much since my arthritis has kicked up. I've been having a lot of pain and stiffness in my joints." Further questioning revealed that Patient W had also developed chronic constipation. The physician examined the patient and ordered laboratory work to be done prior to her next visit, scheduled for two weeks. When the laboratory work returned, it showed an elevated TSH and a decrease in both T3 and T4 levels. Patient W was prescribed a starting dose of levothyroxine at 25 mcg daily. Nurse S spent time teaching the patient about taking the tablet at the same time each day with a full glass of water. Because she was not taking any other medications, there should be no problem with drug interactions; however, the patient was instructed not to take an antacid within four hours of taking the medication in order to avoid problems with malabsorption. A follow-up appointment was scheduled for four weeks with instructions to repeat the blood work one week prior to that appointment. At that time, medication dosages would be adjusted.

The next weekend, Nurse S went to her family reunion, where she was cornered by her cousin, Patient A, asking her advice. The cousin had noticed a hard, painless nodule near his Adam's apple. He was clearly concerned, due in part to the fact that he remembered the course of treatment his father had gone through 30 years prior for thyroid cancer. Nurse S had her cousin tilt his head back, then looked at his throat area while he swallowed some iced tea. She clearly saw a lump protruding prominently from the neck area. She advised him to call his physician for an appointment as soon as possible to be checked out. She told him to expect to have blood work drawn and an ultrasound of the thyroid.

Patient A followed Nurse S's advice and called her two weeks after he had seen the doctor and had the diagnostic work done. The ultrasound had showed nodules, so a biopsy was arranged. When it returned from the pathologist, the biopsy was positive for papillary adenocarcinoma. A total thyroidectomy was done, and Patient A had an uneventful recovery. Pathology showed no metastasis to lymph glands, so he did not have to face a difficult course of treatment like his father had.

The next week at work in the office, there was a problem with the air conditioning unit. The temperature was uncomfortably cold for most patients. However, Patient C, who had come to the office for a work-related physical exam, complained of being hot. She was wearing a sleeveless blouse and was fanning herself despite the cool room. At 27 years of age, Nurse S felt it was unlikely that Patient C was suffering from menopause, so she mentioned the symptom in her notes for the physician. The patient's measured weight was 116 pounds, which she reported was a loss of 12 pounds. She had not been dieting and reported feeling nervous and restless lately, which she attributed to a recent miscarriage.

When the nurse reported these findings to the physician, he ordered TSH, T3, and T4 levels to be drawn. At the follow-up appointment, results from the blood studies showed a decrease in TSH and an increase in both the T3 and T4. All indications were for a diagnosis of hyperthyroidism.

The patient was prescribed methimazole, the thyroid-suppressing medication. In addition, the physician indicated that if there was no improvement in one month, he would order a thyroid scan. Fortunately, like most patients, Patient C responded positively to treatment with the methimazole, and one year later she returned for follow-up with her baby boy.

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