hypothyroidism, TSH levels abnormal, T3 AND T4 Levels

1. Presented by:
B.Venkata Subbareddy

2.  Number of cases collected: 150
 Number of patient counselling done: 150
 ADR’s monitored: 75
 Number of queries collected: 75
 Pharmacist interventions done: 75

3. A 45 years Female patient was admitted in female medical ward with IP
number 1394538 on 02/01/2018.
CHIEF COMPLAINTS:
C/O facial puffiness since 1 month.
PAST MEDICATION HISTORY:
No H/O any significant any medication in the past.
PERSONAL HISTORY AND HABITS:
Non-smoker, Non-alcoholic, married with not known allergies.

4. SUBJECTIVE Continued..,,
HISTORY OF PRESENT ILLNESS:
H/O swelling in front of neck for 2 months, myalgia,
increased tiredness, hoarseness of voice and headache.
H/O Orthopnoea, pain in cheek.
PAST MEDICAL HISTORY:
No H/O DM, HTN. Bike accident 7 years back.

5. VITALS D1 D2 D3 D4 D5
BP(mm of Hg) 110/60 120/80 110/80 120/70 120/80
PR (bpm) 80/min 82/min 78/min 72/min 80/min
RR (bpm) 22/min 21/min 24/min 24/min 22/min
TEMP (f) 98.6 98.5 98.4 98.2 98.6
GENERAL EXAMINATION:
Patient was conscious, Oriented.
SYSTEMIC
EXAMINATION
D1 D2 D3 D4 D5
CVS S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+)
RS NAD NAD NAD NAD NAD
CNS NFND NFND NFND NFND NFND
GIT (P/A) Soft Soft Soft Soft Soft
SYSTEMIC EXAMINATION:

6. Parameter Observed value Normal Value
Hemoglobin 9.5 g/dl 14-17g/dl
ESR 42 mm 5-20mm
Platelets 2.82 cells/mm3
1.0-4.5 cells/mm3
FBS 87 mg/dl 60-110mg/dl
Blood Urea Nitrogen 23 mg/dl 7 - 20 mg/dl
Serum Creatinine 0.7 mg/dl 0.5 - 1.4 mg/dl
T3 0.17ng/ml 0.8-1.6ng/ml
Total T4 0.6µg/dl 4.2-12 µg/dl
TSH 134.94 µIU/mL 0.5 - 4.70 µIU/mL
LAB INVESTIGATIONS:
DIAGNOSIS: Hypothyroidism

7. DRUGS DOSE ROA FREQ NO.OF .DAYS
1 2 3 4 5
Tab. Otilonium bromide 40mg P/O BD     
Tab. Ranitidine 150mg P/O BD     
Tab. Levothyroxine 150mcg P/O OD     
Tab. Ferrous sulfate 300mg P/O OD     -
Tab. Calcium 500mg P/O OD     -
Inj. Diclofenac 2ml/75mg IM BD    - -
Tab. Norfloxacin 400mg P/O BD   - - -
MEDICATION CHART:

8. DISCHARGE ADVICE:
T. Levothyroxine -100mcg, P/O, OD
T. Otilonium bromide 40mg, BD x 1 week.

9.  L-Thyroxine to be taken as single daily dose, ideally on
awakening , at least 30min before eating
 Fibre and bran products (e.g. Ispaghula husk) may impair
absorption as also cholestryramine, colestipol, iron
sulphate , sucralfate, aluminium hydroxide.
 Do not modify dose or stop treatment without
consultation .Over treatment may leads to decreased bone
mineral density and adverse cardiac consequences.
 Increase dietary iodine intake.
 Take iron rich foods, fruits & green leafly vegetables.
 Over treatment may lead to decreased bone mineral density
and adverse cardiac consequences.

10. DRUG INTERACTIONS
Drug –food interaction: Nil
Drug--Drug interaction:
Levothyroxine + calcium carbonate
 Concurrent administration of calcium-containing products may
decrease the oral bioavailability of levothyroxine by one-third in some
patients. Pharmacologic effects of levothyroxine may be reduced.

11. MEDICATION ERRORS
 ANY ALLERGIES NOTED: NO
 DOSE ERROR: Appropriate
 ROUTE OF ADMINISTRATION: Appropriate
 DATE AND TIME OF ADMINISTRATION: Appropriate
 CONFUSION IN WRITING OF THE DRUG: NO
 PATIENT COMPLIANCE: Yes
 PATIENT OPINION REGARDING DRUGS: Satisfactory

12. Pharmacist intervention
Dosing interval of Levothyroxine and
Calcium needs to be changed to achieve maximum
efficacy of Levothyroxine. A time interval of 4
hours is recommended. Monitor serum TSH levels.