Reviewer: S. Randhawa, M.D.
A 61-year-old African American female (AAF) was admitted to the hospital with a chief complaint (CC) of bilateral (B) knee pain for 2 weeks. She was diagnosed with severe osteoarthritis (OA) and opioid pain medications were started.
The patient's last bowel movement (BM) was one week prior to admission and she did not have any BM after that despite multiple laxatives. She also admitted to feeling depressed.
Past medical history (PMH)
Hypertension (HTN), gout, COPD, hypothyroidism following a radioactive iodine treatment for hyperthyoridism in the remote past.
Telmisartan/hydrochlorothiazide (Micardis), furosemide (Lasix), levothyroxine (Synthroid) 100 mcg p.o. q.d, indomethacin, lorazepam.
Family history (FH)
Obese lady in NAD.
Chest: CTA (B).
CVS: Clear S1S2.
Abdomen: Soft, NT, ND, absent BS.
Extremities: the knee examination showed bilateral knee swelling, left greater than right. No joint fluid. Joint tenderness was present. No pitting edema or cyanosis.
The right knee X-rays showed severe degenerative joint disease and several loose bodies in the joint. An orthopedics consultation was called and the patient agreed to a total knee replacement at a later date.
TSH and T4 levels.
What happened next?
TSH was 41.40 mU/L, and her Synthroid dose was increased to 150 mcg po qd. A selective serotonin reuptake inhibitor (SSRI) was started for depression.
The patient constipation persisted despite multiple medications prescribed for the problem.
A list of medications given for the constipation without success.
Her constipation gradually resolved with T4 replacement and lactulose. She will need a recheck of her TSH in 6-8 weeks.
What did we learn from this case?
Constipation is a classic presenting symptom of uncontrolled hypothyroidism.
Uncontrolled HTN and bradycardia are also common presenting symptoms of hypothyroidism.
Opiods, prescribed to this patient for knee pain, made the constipation worse. Most inpatients on opioid therapy will require a stimulant laxative such as senna 2 tabs PO QHS for regular BM.
Hypothyroidism. Bharaktiya et al. eMedicine Specialties, Endocrinology, Thyroid.
Hypothyroidism. Merck Manual.
Treatment of Hypothyroidism. AFP, November 15, 2001.
Constipation. Basson et al. eMedicine Specialties, Gastroenterology, Colon.
Approach to a low TSH level: Patience is a virtue — Cleveland Clinic Journal of Medicine, 2010 http://goo.gl/xY6r4