Vickie Greene is a 31-year-oldAfrican-American woman who presents with her husband Eric(age33) 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   Case 2 • PMH • Infertility × 2 years • Iron deficiency anemia as a teenager • FH • 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. • SH • 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.    Case 2 • Meds • MiraLAX PO daily PRN constipation • Seasonale one PO daily (stopped 2 years ago) • FeSO4 300 mg PO daily • Calcium carbonate 500 mg PO twice daily • Acetaminophen 325–650 mg PO PRN headache, body aches • All • Skin rash from sulfa drug    Case 2 • ROS • (+)Fatiguethatsheattributestostress,(+)occasionalinsomnia,(+)constipation relieved with MiraLAX; (+) occasional headaches relieved with nonaspirin pain reliever; (–) tinnitus, vertigo, or infections; (–) urinary symptoms; (+) dry skin • PhysicalExamination • Gen • Well-appearingAfrican-AmericanwomaninNAD • VS • BP112/74mmHg,P64bpm,RR12,T36.8°C;Wt62kg,Ht5′7′′ • Skin • Slightlydry-appearingskin;(–)rashesorlesions   Case 2 • Neck/Lymph Nodes • (–) Thyroid nodules, possible slight thyroid enlargement; (–) lymphadenopathy, (–) carotid bruits   Lab results Na 138 mEq/L Hgb 13.1 g/dL Anti-TPO antibody + K 4.2 mEq/L Hct 39.2% TSH 9.8 mIU/L Cl 98 mEq/L WBC 6.8 ×103/mm3 Free T4 0.72 ng/dL CO2 25 mEq/L MCV 89 μm3 T. chol 212 mg/dL BUN 8 mg/dL Ca 9.6 mg/dL LDL chol 142 mg/dL SCr 0.7 mg/dL Mg 2.0 mEq/L HDL chol 45 mg/dL Glu 98 mg/dL PO4 3.8 mg/dL TG 125 mg/dL Albumin 4.0 g/dL AST 22 IU/L ALT 19 IU/L T. bili 0.4 mg/dL Alk phos 54 IU/L   Case 2 • Assessment • A 31-year-old woman with infertility, fatigue, other nonspecific symptoms, and an elevated TSH level, suggestive of hypothyroidism   Questions • 1.What subjective and objective information indicates the presence of hypothyroidism? • 2. Assess the severity of this patient’s hypothyroidism based on the subjective and objective information available. • 3. Create a list of the patient’s drug therapy problems and prioritize them. Create an individualized, patient-centered, team-based care plan to optimize the medication therapy for this patient’s hypothyroidism and other drug therapy problems. • 4. What nondrug therapies might be useful for this patient?   Questions • 5. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects? • 6. What changes in her thyroid therapy might be necessary if she does become pregnant?

• Vickie Greene is a 31-year-oldAfrican-American woman who presents with her husband Eric(age33) 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

 

Case 2

• PMH

• Infertility × 2 years

• Iron deficiency anemia as a teenager

• FH

• 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.

• SH

• 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.

  

Case 2

• Meds

• MiraLAX PO daily PRN constipation

• Seasonale one PO daily (stopped 2 years ago)

• FeSO4 300 mg PO daily

• Calcium carbonate 500 mg PO twice daily

• Acetaminophen 325–650 mg PO PRN headache, body aches • All

• Skin rash from sulfa drug

  

Case 2

• ROS

• (+)Fatiguethatsheattributestostress,(+)occasionalinsomnia,(+)constipation relieved with MiraLAX; (+) occasional headaches relieved with nonaspirin pain reliever; (–) tinnitus, vertigo, or infections; (–) urinary symptoms; (+) dry skin

• PhysicalExamination

• Gen

• Well-appearingAfrican-AmericanwomaninNAD

• VS

• BP112/74mmHg,P64bpm,RR12,T36.8°C;Wt62kg,Ht5′7′′

• Skin

• Slightlydry-appearingskin;(–)rashesorlesions

 

Case 2

• Neck/Lymph Nodes

• (–) Thyroid nodules, possible slight thyroid enlargement; (–) lymphadenopathy, (–) carotid bruits

 

Lab results

Na 138 mEq/L

Hgb 13.1 g/dL

Anti-TPO antibody +

K 4.2 mEq/L

Hct 39.2%

TSH 9.8 mIU/L

Cl 98 mEq/L

WBC 6.8 ×103/mm3

Free T4 0.72 ng/dL

CO2 25 mEq/L

MCV 89 μm3

T. chol 212 mg/dL

BUN 8 mg/dL

Ca 9.6 mg/dL

LDL chol 142 mg/dL

SCr 0.7 mg/dL

Mg 2.0 mEq/L

HDL chol 45 mg/dL

Glu 98 mg/dL

PO4 3.8 mg/dL

TG 125 mg/dL

Albumin 4.0 g/dL

AST 22 IU/L

ALT 19 IU/L

T. bili 0.4 mg/dL

Alk phos 54 IU/L

 

Case 2

• Assessment

• A 31-year-old woman with infertility, fatigue, other nonspecific symptoms, and an elevated TSH level, suggestive of hypothyroidism

 

Questions

• 1.What subjective and objective information indicates the presence of hypothyroidism?

• 2. Assess the severity of this patient’s hypothyroidism based on the subjective and objective information available.

• 3. Create a list of the patient’s drug therapy problems and prioritize them. Create an individualized, patient-centered, team-based care plan to optimize the medication therapy for this patient’s hypothyroidism and other drug therapy problems.

• 4. What nondrug therapies might be useful for this patient?

 

Questions

• 5. What clinical and laboratory parameters should be used to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?

• 6. What changes in her thyroid therapy might be necessary if she does become pregnant?