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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Recognize the signs, symptoms, and associated complications of mild and overt hypothyroidism.

  • Identify the goals of therapy for hypothyroidism.

  • Develop an appropriate treatment and monitoring plan for thyroid replacement based on individual patient characteristics.

  • Select an appropriate product for thyroid replacement therapy.

  • Properly educate a patient taking thyroid replacement therapy.

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PATIENT PRESENTATION

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Chief Complaint

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“We are trying so hard to have a baby. Maybe that’s why I’m so tired all the time … too much pressure.”

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HPI

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Vickie Greene is a 31-year-old African-American woman who presents with her husband Eric (age 33) to the Endocrinology Clinic after being referred by her OB-GYN based on the results of some recent blood work. The Greenes have been trying to have a baby for almost 2 years, without Vickie becoming pregnant. The infertility workup done by the OB-GYN showed that Eric had a normal sperm count and sperm motility, and that Vickie had no anatomical abnormalities of her reproductive tract and no evidence of endometriosis. Vickie’s serum sex hormone and gonadotropin levels were all normal. The couple is contemplating in vitro fertilization, but wants to make sure that there are no hormone-related causes of her infertility. Vickie says that for the past few months she has felt increasingly fatigued, which she attributes to the stress of her unsuccessful attempts to become pregnant. She wonders if she is becoming depressed. She also notes that for the past few months, she has had more difficulty concentrating at work, and she has “gained a few pounds.” Over the past 6 months, Vickie has noticed that her periods are a little heavier than normal and are somewhat more irregular. She notes that 2 years ago, she attended a local health fair that provided a variety of laboratory tests. The result of her TSH at that time was 4.2 mIU/L. Her PCP at that time felt that the TSH value was within the normal range and required no follow-up.

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PMH

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  • Infertility × 2 years

  • Iron deficiency anemia as a teenager

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FH

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Father, age 55, has mild COPD; mother, age 54, has type 2 DM, HTN; she has one sister, age 32, who has hypothyroidism. No history of sickle cell trait or disease.

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SH

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Married × 6 years, first marriage for both. No history of STDs. Works as an immigration attorney for a private firm. Social drinker in past but has not used alcohol since attempting to become pregnant; (–) tobacco or illicit drug use.

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Meds

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  • MiraLAX PO daily PRN constipation

  • Seasonale one PO daily (stopped 2 years ago)

  • FeSO4 300 mg PO daily

  • Calcium carbonate 500 mg PO ...

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