Question

A 54 year old female patient comes to the clinic with complaints of feeling fatigued, cold, weight gin, and constipation. The nurse practitioner orders a TSH, which returns elevated. What is the next step?

a. Order another TSH to confirm value
b. Order free T4 and T3
c. Order total T4
d. Order TSH and free T4

Answer 1

After an elevated TSH result, the appropriate next step is to order free T4 and possibly T3 levels to complete the thyroid function profile and better assess the patient's situation, indicating primary hypothyroidism.

Step-by-step explanation:

The patient's symptoms of fatigue, feeling cold, weight gain, and constipation, coupled with an elevated thyroid-stimulating hormone (TSH) level, are indicative of hypothyroidism, a condition where the thyroid gland is underactive. In response to a single high TSH test result, the next step is not to immediately retest TSH. Instead, the clinician should order free T4 and possibly T3 levels to assess the actual thyroid hormone levels in the blood, providing a more complete thyroid function profile. These thyroid hormones are directly responsible for metabolic rate regulation, and their deficiency can lead to symptoms such as weight gain and fatigue.

An elevated TSH level on its own indicates that the pituitary gland is signaling the thyroid to produce more hormones, which may mean the thyroid is not responding correctly. Therefore, measuring the levels of free T4 and possibly T3 is essential to confirm the diagnosis and assist in creating an appropriate treatment plan. If both TSH is high and free T4 is low, it typically confirms a diagnosis of primary hypothyroidism.

The final answer in this scenario, and the appropriate next step, would be to order free T4 and possibly T3 levels to confirm the initial findings suggested by the elevated TSH.