VG is a thirty-one-year-old female who comes in for a routine follow-up. She reports that she has been feeling excessive fatigue over the last month. She also notes that she is having some problems at work, not only because of her fatigue but also because of difficulty concentrating. She also notes that she has gained 10 pounds over the last month, and she is unable to identify the cause of the weight gain. She also notes that her periods are a little heavier and more irregular. She is currently taking daily ferrous sulfate and over-the-counter calcium. According to her medical record, she had a TSH level of 4.2 mIL/L about a year ago. Although this is slightly elevated, no further follow-up was deemed necessary at the time. Repeat blood work today reveals a TSH level of 9.8 mIL/L and a free T4 of 0.72 ng/dL. Answer the following questions:
- What additional findings on the physical exam would you look for?
- What implication does the previous TSH level have?
- What therapy would you institute?
- If VG becomes pregnant, what adjustment, if any, would be needed in her thyroid medication?
For medications, include dosages and schedules. Include highlights of patient teaching and/or lifestyle alterations. Support your decisions with at least one reference to a published clinical guideline and one peer-reviewed publication.