Patient’s name: Sarah Welsh
Age: 45 years old female
Past medical history
Drug history and Allergies
You are Sarah Welsh, a 45-year-old woman calling to discuss your recent blood test results.
You were diagnosed with an underactive thyroid (hypothyroidism) 6 months ago because you were experiencing constant tiredness, dry skin, and constipation. Your symptoms have improved slightly since starting Levothyroxine, but you are still struggling with the same issues, and they are affecting your job as a medical secretary.
You recently had your medication dose increased from 100mcg to 125mcg three months ago, but you don’t feel much better. You are now worried about what might be causing this.
ONLY SAY THIS IF ASKED:
You take multivitamins with your thyroid medication in the morning because you thought vitamin deficiencies might be the cause of your symptoms.
Social History
Lifestyle: You live with your husband and two children. Your husband is very supportive and helps out at home.
Job: You work as a medical secretary, but your tiredness makes it hard to stay on top of your tasks, and you feel it is impacting your job performance.
Habits: You don’t smoke, and you don’t drink alcohol.
Menstrual History: Your do not see your periods but you think this is due to your Mirena coil for contraception.
Ideas, Concerns, and Expectations
Ideas: You suspect your symptoms could be due to a vitamin deficiency or the Levothyroxine dose needing adjustment.
Concerns: Your symptoms are affecting your ability to work, and you are worried this might continue.
Expectations: You want the doctor to explain your blood test results and help you feel better.
Seen by Dr. Ifeanyi Onuoha (Clinical practitioner access role)
3 months ago
History: Known Hypothyroid. Current TSH levels at 12.1 and patient still symptomatic.
Examination: No neck swelling, no visual symptoms, BP120/85mmHg, weight 75kg.
Plan: Adjust levothyroxine dose—to be increased from 100mcg to 125mcg OD, review in 3 months. Worsening advice given.
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Test
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Result
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Reference Range
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Previous Result (3 months ago)
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Patient booked routine appointment to discuss concerns
History
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