NURSING-NUR/590B University of Florida – A 26-year-old woman is in the clinic today for evaluation of weight gain and fatigue. She is 5 feet 6 inches and weighs 175 pounds.

QUESTION

A 26-year-old woman is in the clinic today for evaluation of weight gain and fatigue. She is 5 feet 6 inches and weighs 175 pounds. Prior to her pregnancy, she weighed 130 pounds and her maximum weight during pregnancy was 155 pounds. She is now 18 months postpartum and continuing to gain weight despite no change in diet or activity. She reports that the fatigue is getting worse even though her daughter is sleeping reliably through the night and the patient feels she is getting plenty of rest. She takes no other medications and has no significant medical history. Her vital signs today are HR 68, BP 108/60, RR 10, temperature 97° F. The nurse practitioner orders a CBC, TSH, and T4.

Discussion Questions

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  1. What sources of fatigue is the nurse practitioner evaluating with the CBC, T4, and TSH?
  2. What other history or clinical findings would be indicative of hypothyroidism?
  3. The patient’s laboratory values show an elevated TSH and a low T4. What does this mean?
  4. After starting the patient on thyroid hormone replacement, the nurse practitioner asks the patient to return in 8 weeks to check her TSH level. What is the purpose of this test? What should be done if the test result is abnormal?

ANSWER

Evaluation of Fatigue and Weight Gain: Understanding Hypothyroidism

Introduction

Hypothyroidism is a common endocrine disorder characterized by an underactive thyroid gland, leading to decreased production of thyroid hormones. It can manifest with symptoms such as weight gain and fatigue. In this case, a 26-year-old woman presenting with weight gain and fatigue post-pregnancy is being evaluated by a nurse practitioner. This essay will discuss the sources of fatigue being evaluated through a CBC (Complete Blood Count), TSH (Thyroid-Stimulating Hormone), and T4 (Thyroxine) tests, along with additional clinical findings indicative of hypothyroidism. Furthermore, it will explain the significance of elevated TSH and low T4 levels and the purpose of follow-up TSH testing after thyroid hormone replacement.

Sources of fatigue evaluation

The nurse practitioner is evaluating several potential sources of fatigue in the patient. One of the main considerations is hypothyroidism, which is supported by the symptoms of weight gain, fatigue, and the laboratory order of TSH and T4 tests (Kim, 2020). However, it is important to rule out other causes that can contribute to fatigue, such as anemia and infections, which can be assessed through the CBC test. A CBC measures various components of the blood, including red blood cells, white blood cells, and platelets, providing valuable information about overall health and identifying any abnormalities.

Indicative history and clinical findings of hypothyroidism

Apart from the symptoms of weight gain and fatigue, several other history and clinical findings can support a diagnosis of hypothyroidism. These may include:

Cold intolerance: Patients often report feeling excessively cold, even in normal temperature environments.

Dry skin and hair: Hypothyroidism can cause dryness of the skin, brittle hair, and hair loss.

Constipation: Slowed gastrointestinal motility is a common feature of hypothyroidism, leading to constipation.

Menstrual irregularities: Hypothyroidism can affect the menstrual cycle, leading to heavy or irregular periods.

Depression and cognitive changes: Patients may experience mood disturbances, difficulty concentrating, and memory problems.

Elevated TSH and low T4 levels

The laboratory values of elevated TSH (Thyroid-Stimulating Hormone) and low T4 (Thyroxine) indicate primary hypothyroidism. TSH is released by the pituitary gland to stimulate the thyroid gland to produce and release thyroid hormones. In primary hypothyroidism, there is decreased production of thyroid hormones by the thyroid gland itself, resulting in a compensatory increase in TSH levels (Pirahanchi, 2022). The low T4 levels indicate inadequate levels of circulating thyroid hormones, which are essential for maintaining the body’s metabolism, energy levels, and overall well-being.

Purpose of TSH testing after thyroid hormone replacement

After starting the patient on thyroid hormone replacement, the nurse practitioner plans to check the patient’s TSH level after 8 weeks. The purpose of this follow-up test is to monitor the patient’s response to the thyroid hormone replacement therapy (Schäffler, 2010). The goal is to achieve optimal thyroid hormone levels within the normal range, ensuring that the patient’s symptoms improve and the metabolism is adequately supported.

If the test result is abnormal

 If the follow-up TSH test shows abnormal results, it may indicate suboptimal thyroid hormone replacement therapy. In such cases, the nurse practitioner may adjust the dosage of thyroid hormone medication based on the patient’s TSH levels. Regular monitoring of TSH levels allows healthcare providers to fine-tune the dosage to maintain appropriate thyroid hormone levels, ensuring symptom relief and overall well-being.

Conclusion

When evaluating a patient with fatigue and weight gain, it is crucial to consider potential causes, including hypothyroidism. Clinical findings, such as cold intolerance, dry skin, and menstrual irregularities, along with laboratory results showing elevated TSH and low T4 levels, can support a diagnosis of primary hypothyroidism. Thyroid hormone replacement therapy aims to restore optimal thyroid hormone levels and alleviate symptoms. Regular monitoring of TSH levels allows healthcare providers to adjust medication dosage as needed to ensure adequate treatment. By addressing the underlying cause of fatigue and weight gain, the patient’s overall health and well-being can be significantly improved.

References

Kim, M. I. (2020, July 14). Hypothyroidism in Older Adults. Endotext – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK279005/

Pirahanchi, Y. (2022, May 8). Physiology, Thyroid Stimulating Hormone. StatPearls – NCBI Bookshelf. https://www.ncbi.nlm.nih.gov/books/NBK499850/ 

Schäffler, A. (2010). Hormone Replacement After Thyroid and Parathyroid Surgery. Deutsches Arzteblatt International. https://doi.org/10.3238/arztebl.2010.0827 

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