October 14, 1999

The following excerpt is from Blonde Bimbo’s October 14th, 1999 report which reads as follows,  “I saw Widebertha on October 14th, 1999 at your request.  She, of course, subsequently had radioactive iodine and became hypothyroid.  On last review in March of 1999 while on levothyroxine 175 mg daily her TSH was 0.2 and she felt quite normal.  I am not sure where Blonde Bimbo got the idea that I was feeling quite normal.”

By that time the nasty hypo symptoms had been going on for almost a year.  Blonde Bimbo kept reassuring me that if I gave it a few more months all would be well!   Blonde Bimbo went on to say, “Widebertha tells me that over the spring she has developed problems with restless legs.   The restless leg problem became worse and did not respond to an increase of her physical activity over the summer.   I understand that she changed to levothyroxine 150 mg alternating with 175 mg in September and since then her legs have been better. Other concerns at the present time are chronic loss of energy and a continuing weight gain. By our scales she has gained 4.6 kg. since she was seen here in March.   She also notices that the weight gain is more of a central distribution than it was previously.  She feels bloated with this and still has some insomnia.  Of note menses are very sporadic with the last period being in June of 1999. She denies any hot flashes or any major emotional changes.  She really has no clear cut symptoms of hyper or hypothyroidism at the present time apart from the non-specific ones mentioned.  The only other thing of note is she has had problems with periorbital edema since April or May of this year.   She has some very occasional grittiness of the eyes but no injection, diplopia or pain on movement of the eyes. The only thing of note is that she has been started on Metoprolol for hypertension.”

“Physical examination revealed a middle aged woman.  Blood pressure was 170/90 sitting bilaterally.  Pulse was 60 and regular.  On head and neck exam she had normal range of movement of both eyes.  No proptosis or lid lag was noted.  She does have periorbital edema more marked on the left than on the right.  No adenopathy was present in the neck.  Her thyroid is about 25 gm. in size.  Chest, cardiovascular and abdominal exams were normal.  A screening neurological exam was within normal limits.”

“Widebertha is clinically euthyroid on exam at the present time and I doubt that many of her residual symptoms relate to hyperthyroidism. Given her recent oligomenorrha I would wonder whether some of the weight gain and fatigue is perhaps peri menopausal symptomatology.   Having said this assuming her TSH is normal on her current levothyroxine replacement the only other thing that could be tried would be a trial of combined T3 T4 replacement which does give subjective benefit in some people.  She is interested in this and I have taken the liberty of giving her a prescription for Cytomel 112.5 mg daily to take together with the levothyroxine 112 mg. daily.  With regards to the periorbital puffiness this may well be due to some soft tissue changes from thyroid opthalmopathy although she doesn’t have much else to suggest at the present time.  I have advised her to elevate the head of the bed and I have taken the liberty of placing her on a low dose diuretic i.e. Moduret 1 tab o.d. to see if this helps her.  Hopefully this will have a beneficial effect on her hypertension as well.  I have asked her to come back and see me after she has been on the combination T3 T4 therapy for about eight weeks to see how this works out for her.”

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