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      Sarah Welsh

      Age: 45 years old female

      Examiner

      Station List
      Patient
      Doctor
      Full Case

      Marking Scheme

      History

      • Ask about hypothyroid symptoms—Tiredness, cold intolerance, skin changes, hair loss, weight gain, neck swelling, neck pain, mood changes, menstrual irregularities, constipation.
      • Ask about compliance with medications and how she is taking her medications.
      • Ask about use of other medications like multivitamins.
      • Ask about simultaneous intake of LT4 with food and drink such as milk, coffee, grapefruit juice, soya products, and papaya which can impair absorption of LT4.
      • Ask about gastrointestinal conditions causing malabsorption such as coeliac disease, Helicobacter pylori gastritis, atrophic gastritis/pernicious anaemia, giardiasis, and inflammatory bowel disease, which may reduce absorption of LT4 in the gut.
      • Ask about diarrhoea, PR bleeding, bloating, epigastric/abdominal pain.
      • Ask about weight gain which may increase LT4 requirements.
      • Make a diagnosis of uncontrolled hypothyroidism likely due to use of multivitamins which is not allowing good absorption of medication.

      Explain to patient: Sarah, your blood results show that your thyroid levels are still underactive, but before we increase your dose of Levothyroxine, I’d like to address an important factor. Taking Levothyroxine with multivitamins can interfere with how well your body absorbs the medication. This might be why your thyroid levels haven’t improved as much as we expected.

      I also understand that you thought your symptoms might be due to low vitamin levels.

      However, your blood tests show that your vitamin D, B12, folate, and iron levels are all normal. This makes it much more likely that your symptoms are due to your underactive thyroid. The fact that your symptoms have slightly improved since starting the thyroid medication supports this as well.

      I’d recommend taking your Levothyroxine on an empty stomach with water, ideally first thing in the morning, and waiting at least 4 hours before taking your multivitamins or any other supplements. Let’s repeat your blood tests in 6-8 weeks to see if this change helps improve your thyroid levels and your symptoms.

      If your thyroid levels still aren’t where they need to be after that, we’ll look at adjusting your dose further. This way, we can make sure you’re on the right amount of medication without making unnecessary changes.

      Management

      Management

      • Advise patient to take levothyroxine on an empty stomach, 4 hours before taking any other medication or 60 minutes before any meal as this will allow for good absorption of medication and there may not be any need to increase the dose at the moment.
      • Offer blood test to also rule out conditions which may impair absorption and occur with hypothyroidism (Autoimmune) like coeliac disease, perniciousanaemia, stool for H. pylori if epigastric pain present (In this case, this may not be necessary at this stage as it is obvious that taking her multivitamins same time with levothyroxine is responsible for the poor absorption).
      • Offer blood test for lipids to help in calculating Q-Risk (Part of health promotion in hypothyroid patients.
      • Offer amended duties/light duties for work.
      • Offer follow up in 6-10 weeks to see how she is doing –You can repeat TSH test at that stage if she is still not better or getting worse, if not, repeat test in 3 months.
      • Offer leaflet to read more about hypothyroidism
      • Safety net if things are getting worse, getting confused/seizures (Myxoedemacoma) to seek urgent help/ medical advice.