Among my accounts, this is the most interesting and fascinating...
HISTORY OF PRESENT ILLNESS: The patient is 59-year-old woman who was diagnosed with hypothyroidism in October xxxx. She presented with fatigue and weight gain. She was started on Synthroid 0.2 mg once a day. At the time, her TSH was 35.04. Repeat laboratory testing in December showed a TSH at 0.07 and her dose was reduced to 125 mcg. Her repeat thyroid function tests in February showed a TSH of 0.16. She is currently complaining of continued fatigue, total weight gain of 25 pounds since October, difficulty losing weight, cold intolerance, and dry skin. She takes her medication in the morning with her other medications but no supplements. She waits for an hour before eating breakfast. She was apparently started on a generic preparation, developed the rash to this, but is now on the brand Synthroid. She has never had any previous thyroid disorder, no history of nodules or lumps in her neck. She has had no compressive symptoms. She has noted a significant increase in the size of her neck, but this is in the area below her chin.
The patient also had her estrogen level reduced about 1 year ago. She had been on 2 mg daily since 1982 when she had a hysterectomy. The dose was cut in half to 1 mg about 1 year ago. She believes some of her symptoms began at that time as well, particularly the dryness and reduction in temperature.
PAST MEDICAL HISTORY:
Hypothyroidism, diagnosed xx/xx.
Postmenopause, on HRT.
Depression, on Wellbutrin.
Hearing loss requiring hearing aid in the left ear.
PAST SURGICAL HISTORY:
Hysterectomy with ovaries intact in xxxx.
Hemorrhoid surgery xx years ago.
Pregnancies, x, with x children.
ALLERGIES: Unknown, except for the generic thyroxine.
FAMILY HISTORY: Father died at60 with heart valve problems. The mother is 88; she is recently diagnosed with hypothyroidism and osteoporosis. She has 2 brothers, age 53 and 57; they are healthy. She has 4 children, 27 through 40, who are also healthy, no diabetes, no other tyroid disease, cancer, or heart disease in the family.
Synthroid 125 mcg daily.
Wellbutrin 150 mg SR daily
Detrol LA 2 mg daily.
Estradiol 1 mg daily.
Bextra 10 mg as needed.
Super B-complex with flaxseed supplement.
SOCIAL HISTORY: She is originally from California. She is a retired puppeteer. She is married.
HABITS: Nonsmoking. Consumes 1 alcohol a day. Caffeine none.
REVIEW OF SYSTEMS: General: Overall, the patient feels well, but she is very unhappy about not being able to lose weight. HEENT: Negative. Cardiorespiratory: Negative. Gastrointestinal: Negative. Genitourinary: Her symptoms are controlled with Detrol. Endocrine: Amenorrhea, cold intolerance and dry skin ; she has never had an elevated glucose. She had a bone density scan done many years ago and has lost 2 inches in height. She is not following any diet at this time, but is contemplating on a weight-loss diet. She did look into Madura. She exercises 5 times a week, going to Curves for 30 to 45 minutes. Musculoskeletal: She has some osteoarthritis. She is on occasional Bextra. Vascular: She has had varicosities, and some end-of-the-day edema in her ankle. Neurologic: She occasionally can feel some numbness in her feet. Hematologic: Negative. Psychiatric: Her depression has been under good control.
PHYSICAL EXAMINATION: General: The patient is a healthy-appearing 59-year-old woman. She is no apparent distress. Vital signs: Blood pressure 126/70, pulse 64 and regular. Weight 159 1/2 pounds. Integument: Cool and dry. Normal texture, smooth and some old stretch marks on her abdomen, nothing new. Hair: Normal in distribution, no hirsutism and balding. HEENT: There is no Cushingoid appearance. There is increased soft tissue under the chin in the midline, but no supraclavicular increase in fat or subcervical fat pad or facial cheek fat distribution. EOMI PERRLA. Normal eyes and nose. There is no periorbital edema. Oropharynx is unremarkable. Neck: The thyroid gland is small with no nodule. Lymph nodes: Negative. Chest: Clear to auscultation on anterior and posterior. COR: Regular rate and rhythm. No murmur, gallop or rub heard. Abdomen: Soft, flat and normoactive bowel sounds. No hepatosplenomegaly and nontender. Extremities: No edema. Neurological: Cranial nerves intact. DTR is 2+/2 with normal sensation and motor intact.
LABORATORY DATA: From October laboratory testing included a normal CBC, a chemistry panel with a fasting glucose of 75.
Recent low TSH.
Postmenopause on estrogen.
Abnormal weight gain.
DISCUSSION: At this time we will recheck thyroid function test to see if the dose needs to be adjusted. I discussed with her the lag in time for normalization of thyroid function once the dose is changed, as well as the lag in time for clinical symptoms to improve as well. Autoantibodies are supposed to have been drawn today to see whether or not this is consistent with Hashimoto's thyroiditis. We will recheck her estrogen level as well. I am reluctant at this point to increase her estrogen to help relieve some of her symptoms until the thyroid level has been completely normalized. We will also order a bone densitometry at this time as it has been many years since she had one.
We briefly discussed weight loss, dieting, and exercise principles. She is going to work on this on her own and is contemplating on program at this time.
We will have her return to the office in 3 months. We will contact her concerning her laboratory results.
HISTORY OF PRESENT ILLNESS: The patient reports that she was recently diagnosed with pituitary adenoma in June of 1999 when she presented for an annual Pap examination. She had galactorrhea of both breasts at the time. Her prolactin level was checked and it was high at 100. An MRI was done, which demonstrated a 5-mm pituitary adenoma. She was started on bromocriptine; however, she had a poor response in her prolactin level. This has been switched to Dostinex 0.5 mg 2 times a week. She has been on this since then. She reports good control of her prolactin when she is on the Dostinex. Her results will go down to below 10. Her menstrual cycles are also regular when on Dostinex. When she was originally diagnosed, she was on oral contraceptives. Her menstrual cycles have remained normal on this. Birth control pills were discontinued, and she had irregular cycles until she was placed on the Dostinex. She had a lack in medication last year due to a change in the insurance. During that time, her prolactin level increased to 190. Her menstrual cycles were also irregular at that time. Recently she has gone off the Yasmin to become pregnant. Her last menstrual cycle was on February 20th, which was at the end of the last pack of Yasmin dose. She has not had a menstrual cycle since then, but has had a repeated home pregnancy test negative. She missed Dostinex for 1 week while she was traveling on spring break, and attributes the irregularity to this, too. She has been back on the Dostinex for 1 to 2 weeks. She has had repeated MRI throughout the year. I have a report from the most recent one, which was in 5/04. The pituitary tumor measured 78 mm. It was in the right aspect of the gland and it showed no significant change from prior MRIs. She reports that the size does vary on MRI between 5 to 8 mm. In addition, she has seen an ophthalmologist on a regular basis and has never had any problems with her visual field. She has never had any symptoms such as headache or change in vision. She has no galactorrhea.
PAST MEDICAL HISTORY:
No surgeries, no fracture or injuries.
Gravida 1 para zero, 1998.
ALLERGIES: None known
FAMILY HISTORY: Her father is 46 and had a brain aneurysm a number of years ago. Her mother is 40 and is doing well. She has 3 siblings, all well, ages 7, 18 and 20. Her maternal grandfather had prostate cancer and a stroke. Her maternal grandmother had glaucoma. There is no thyroid disease, diabetes, endocrinopathies, or pituitary tumors in this family.
MEDICATIONS: Dostinex 0.5 mg twice a week. Multivitamins daily.
SOCIAL HISTORY: She is originally from xxxx. She is married. She is currently working as a substitute teacher and recently graduated.
HABITS: No cigarettes, no alcohol, 1 caffeine a day.
REVIEW OF SYSTEMS: General: Overall, the patient feels well. HEENT: Negative. Cardiorespiratory: Negative. Gastrointestinal: Negative. Genitourinary: Negative, except for as in history of present illness. Endocrine: She is complaining of hair loss at this point in time. Her weight has been stable. She exercises 30 minutes 3 days a week. Musculoskeletal: Negative. Vascular: Negative. Neurologic: Negative. Hematologic: Negative. Psychiatric: Negative.
PHYSICAL EXAMINATION: General: The patient is a healthy-appearing 24-year-old woman. She is no apparent distress. Vital signs: Blood pressure 120/72, pulse 72 and regular. Weight 182 1/2 pounds. Integument: Cool and dry. Normal texture and color. Palms were dry. Nails are normal. Hair: Normal in distribution, no hirsutism and no hair loss noted. HEENT: No Cushingoid appearance. EOMI PERRLA. Normal eyes and nose. There is no periorbital edema. Oropharynx is unremarkable. Neck: The thyroid gland is normal with no nodule. Lymph nodes: Negative. Chest: Clear to auscultation on anteriorly and posteriorly. Back: No dorsocervical fat pad. [5:23] COR: Regular rate and rhythm. No murmur, gallop or rub heard. Abdomen: Soft, flat with normoactive bowel sounds. No hepatosplenomegaly, no stria and nontender. Extremities: No edema. Neurological: Grossly intact. DTR is 2+/2 with normal relaxation phase, no tremors. The visual fields were intact to confrontation.
Irregular menstrual cycle.
DISCUSSION: The patient probably has a prolactin-secreting adenoma given the degree of elevation of prolactin and the size of the tumor being under 1 cm. It has responded well to Dostinex when the patient has been on the medication. We will check prolactin level. At this time, it may be mildly elevated given the fact that she has not been on the Dostinex regularly in the last months or so. We also will check a serum pregnancy test as her menstrual cycle is late at this point in time. She will continue on the Dostinex at this time. Should she become pregnant, it will be discontinued and she will notify our office. I have recommended that she wait a total of 3 months prior to getting pregnant off of the contraceptive pills. She is to keep track of her cycle, and from the day that her cycle is due, she will need to begin her pregnancy test until she resumes her period or the test is positive. We will also check other pituitary functions at this time, including thyroid, IGF-1, and gonadotropins, and estrogen.
I would like to thank you for having referred this patient for evaluation and I have requested her to follow up with us in 3 months. She is to call us if she becomes pregnant. Please let me know if you have any questions or concerns regarding her.