Dr. Charles and class,

Following is my findings in part 2 of our case study for week 6.

Primary Diagnosis

My primary diagnosis for this patient is hypothyroidism (low thyroid) with an ICD-10 of

E03.9 (“ICD10Data.com,” 2018). As discussed in part 1 of the case study, the patient has some

classic symptoms of cold intolerance, lethargy, tiredness, diastolic HTN, low basal metabolic rate

(shown by a weight gain of 5lbs in 6 months), muscle cramps, constipation, generalized dry skin,

and course hair (Jonklaas et al., 2014). Now that the labs are resulted, we can say with

confidence that the primary differential is hypothyroidism, since the TSH is elevated (Samuels et

al., 2017) and the free T4 is low (Fallahi, Ferrari, Ruffilli, & Antonelli, 2016).

Treatment Plan

Medication

Levothyroxine 25mcg

Disp #30

Sig: 1 tablet daily, take 1 hour before breakfast or 3 hours after evening meal

RF: 1

(Jonklaas et al., 2014).

Further Tests

I did not initially order a CBC in part 1 of my case study assignment, though I did want to

do it; I simply could not find the appropriate EBP at the time to back it up. I have since found

better clinical guidelines, so for further testing, I would do a CBC because I want to know what

the hemoglobin is to rule out any anemia, which hypothyroidism can be associated with

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(Jonklaas et al., 2014). In my initial lab orders, I ordered a lipid profile, which I would still order

because it is also associated with hypothyroidism (Jonklaas et al., 2014). I would additionally

order a complete metabolic panel, specifically to know what the sodium is and what the serum

glucose is, since both of those can be associated with hypothyroidism as well (Jonklaas et al.,

2014). If a nodular thyroid is suspected, then an ultrasound of the thyroid could be ordered, but

I do not suspect nodules in this patient due to the fact that upon physical exam, the thyroid felt

smooth. If at some point this changed, then I would order the ultrasound (Jonklaas et al., 2014).

Patient Education

The patient needs to take the levothyroxine as directed, making sure that it is taken at

least 60 minutes before breakfast or at least three hours after dinner because food decreases

the absorption of the levothyroxine (Jonklaas et al., 2014). The patient also needs to make sure

that she does not take her calcium supplement within four hours of taking her levothyroxine, as

the calcium will interfere with the absorption of the levothyroxine as well (Jonklaas et al., 2014).

She should start feeling some improvement within 1-2 weeks, with the symptoms

resolving in 3-6 months (Jonklaas et al., 2014). She needs to understand that this is going to be

lifelong therapy, it is not something that resolves with a little bit of medication for a few weeks.

She needs to be aware of signs of toxicity (tremor, tachycardia, nervousness) and alert the office

if this occurs (Jonklaas et al., 2014).

A high-fiber diet is recommended to prevent constipation, which would be important

anyway since she has complained of constipation already (Hollier, 2014). A diet for weight-loss is

recommended, especially a low-fat diet since patients with hypothyroidism are more prone to

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