| Course | NUR-7072 Adult Primary Care Part II |
|---|---|
| Module | Module 5 |
| Paper type | Case paper: endocrine care |
| Length | About 1,019 words, 6 pages |
| Format | APA 7 student paper |
| School | Thomas Edison State University |
| Program | M.S. in Nursing, Family Nurse Practitioner |
| Updated | October 2026 |
Free sample paper for NUR 7072 Module 5
Tired, Cold and Slow: Starting Levothyroxine for Overt Hypothyroidism
Student Name
M.S. in Nursing, Family Nurse Practitioner, Thomas Edison State University
NUR-7072: Adult Primary Care Part II
Mentor Name
Month Day, Year
Tired, Cold and Slow: Starting Levothyroxine for Overt Hypothyroidism
The Patient
Carol Jensen, an invented 52-year-old bank teller, has felt tired for about six months despite sleeping nine hours. She is cold when coworkers are comfortable, has gained 12 pounds without changing her diet, has dry skin and constipation and says her thinking feels "slow." Her periods stopped a year ago. Her sister has Hashimoto's thyroiditis. She takes a calcium supplement and omeprazole for reflux. Her examination showed a slightly enlarged, firm, nontender thyroid, dry skin and a delayed relaxation phase of the ankle reflexes. Her heart rate was 58 and her blood pressure 128/86.
Diagnosis
Chaker et al. (2017) explain that primary hypothyroidism is diagnosed by an elevated thyroid-stimulating hormone with a low free thyroxine, while subclinical hypothyroidism is an elevated TSH with a normal free T4. Symptoms such as fatigue, weight gain, cold intolerance and constipation are common but nonspecific, so laboratory confirmation is essential. In iodine-sufficient countries, chronic autoimmune thyroiditis, also called Hashimoto's thyroiditis, is the most common cause, and antibodies to thyroid peroxidase are present in most affected people. Ms. Jensen's TSH was 11.8 and her free T4 0.7 ng/dL, below the laboratory's reference range, on two tests six weeks apart. Her thyroid peroxidase antibodies were strongly positive. She has overt primary hypothyroidism due to autoimmune thyroiditis.
A Contrast: Subclinical Disease in Older Adults
Stott et al. (2017) gave 737 people aged 65 or over who had persisting subclinical hypothyroidism, a TSH of 4.60 to 19.99 with normal free T4, either levothyroxine or placebo by random assignment. At one year, scores for hypothyroid symptoms and fatigue were no better with levothyroxine than with placebo. The trial supports a cautious approach to treating mildly elevated TSH in older people, in whom TSH normally rises with age. Ms. Jensen's case differs in two ways: she is younger, and her free T4 is low, which defines overt disease that clearly warrants treatment.
Treatment Guidance
Jonklaas et al. (2014) recommend levothyroxine alone as the standard treatment for hypothyroidism. For otherwise healthy younger adults, a full replacement dose, calculated at roughly 1.6 mcg for each kilogram of body weight per day, can be started; for older patients and anyone with coronary disease, starting low, commonly at 25 to 50 mcg, and increasing slowly is safer. Levothyroxine is best absorbed on an empty stomach, taken consistently either 60 minutes before breakfast or at bedtime at least three hours after the last meal. Calcium, iron, some antacids and proton pump inhibitors can reduce absorption. A TSH level is due four to six weeks after any start or dose change, with the goal of bringing it into the reference range. The guideline does not recommend routine combination therapy with liothyronine.
| Source | Key point | Application to Ms. Jensen |
|---|---|---|
| Chaker et al. (2017) | High TSH with low free T4 is overt disease; autoimmunity is the usual cause | Overt Hashimoto's hypothyroidism |
| Stott et al. (2017) | Older adults with subclinical disease gained no benefit from treatment | Her overt disease is different |
| Jonklaas et al. (2014) | Levothyroxine alone; dose by weight and age; TSH in four to six weeks | Start near full dose and recheck |
Plan
Ms. Jensen weighs 78 kg and has no heart disease, so a full replacement dose would be about 125 mcg. Because she is in her fifties and her heart rate is slow, I started 100 mcg daily, close to full replacement, with a plan to adjust. She will take it on waking with water, at least an hour before breakfast and coffee. Her calcium supplement was moved to the evening, at least four hours apart from the levothyroxine. Her omeprazole may reduce absorption, so we noted that her dose might need to be higher while she takes it and agreed to reassess whether she still needs the omeprazole.
Teaching
I explained that she will need levothyroxine for life, that energy usually improves over several weeks and that she should stay with the same manufacturer's product when possible, since switching can change her TSH. She was told to report palpitations, tremor, insomnia or chest pain, which can signal too high a dose.
Follow-Up
TSH will be checked in six weeks, and the dose adjusted in 12.5 to 25 mcg steps until TSH is in the reference range. After the dose settles, a yearly TSH is enough unless her medicines or weight change. Because autoimmune thyroid disease is associated with other autoimmune conditions, any new symptoms such as joint pain or changes in blood sugar will be investigated.
Cardiovascular and Bone Considerations
Untreated hypothyroidism raises LDL cholesterol, so her lipid panel will be repeated after she is euthyroid. Overtreatment, on the other hand, makes atrial fibrillation and loss of bone density more likely, especially after menopause, which is why her TSH will be kept within range rather than suppressed.
Why Not Add T3?
Some patients ask about combination therapy with liothyronine or desiccated thyroid after reading about it online. Jonklaas and colleagues found insufficient evidence that combination therapy is better than levothyroxine alone and do not recommend it for routine use. I told Ms. Jensen that if she still felt unwell once her TSH was in range, we would look for other causes before considering changes.
If Symptoms Persist
Some patients continue to feel tired even with a normal TSH. In that case, anemia, vitamin B12 deficiency, sleep apnea, depression and other autoimmune conditions would be considered, rather than simply raising the levothyroxine dose and risking overtreatment.
Bone Health
She was also reminded about calcium and vitamin D intake and weight-bearing exercise for bone health after menopause.
Limits
The TRUST trial studied only older adults with subclinical disease. Symptoms may lag behind laboratory improvement. The patient is invented.
Conclusion
Chaker and colleagues provided the diagnostic criteria that confirmed overt autoimmune hypothyroidism, Stott and colleagues showed why mild subclinical disease in older adults is often left untreated and Jonklaas and colleagues guided the dose, timing and monitoring of levothyroxine. Starting near full replacement, separating calcium, considering the PPI and checking TSH in six weeks give Ms. Jensen a careful path back to normal thyroid function.
References
Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. https://doi.org/10.1016/S0140-6736(17)30703-1
Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., Cooper, D. S., Kim, B. W., Peeters, R. P., Rosenthal, M. S., & Sawka, A. M. (2014). Guidelines for the treatment of hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid, 24(12), 1670-1751. https://doi.org/10.1089/thy.2014.0028
Stott, D. J., Rodondi, N., Kearney, P. M., Ford, I., Westendorp, R. G. J., Mooijaart, S. P., Sattar, N., Aubert, C. E., Aujesky, D., Bauer, D. C., Baumgartner, C., Blum, M. R., Browne, J. P., Byrne, S., Collet, T.-H., Dekkers, O. M., den Elzen, W. P. J., Du Puy, R. S., Ellis, G., . . . Gussekloo, J. (2017). Thyroid hormone therapy for older adults with subclinical hypothyroidism. New England Journal of Medicine, 376(26), 2534-2544. https://doi.org/10.1056/NEJMoa1603825
NUR 7072 Module 5 instructions, in plain terms
Endocrine care is listed in TESU's catalog description of NUR-7072, and because the syllabus is not available publicly, this fifth paper is modeled as a hypothyroidism case. Present an adult with symptoms and repeated thyroid tests, distinguish overt from subclinical disease and identify the likely cause. Explain when treatment is and is not warranted, using trial evidence on subclinical disease. Pick a starting dose and justify it by weight, age and cardiac status, teach correct timing and interactions and plan TSH monitoring and dose adjustment. Address risks of both under- and overtreatment. Some sections ask for a hyperthyroidism or thyroid nodule case instead. Check whether laboratory reference ranges must be stated.
Inside the NUR 7072 Module 5 example
Carol Jensen, an invented 52-year-old bank teller, has fatigue, cold intolerance and weight gain, with a TSH of 11.8, low free T4 and positive antibodies on repeat testing. Chaker and colleagues' criteria confirm overt autoimmune hypothyroidism. The TRUST trial is used to explain why older adults with mild subclinical disease often go untreated, and all three sources are compared in a table. Levothyroxine 100 mcg is started, calcium is moved to the evening and the omeprazole interaction is noted. Teaching, a six-week TSH check, cardiovascular and bone considerations, limits and a conclusion follow. Sections on combination therapy and on symptoms that persist despite a normal TSH come before the limits.
Where the marks sit in the NUR 7072 Module 5 rubric
Thyroid papers score well when repeated TSH and free T4 results, read correctly, support the diagnosis and when the cause is identified. Readers look for a clear distinction between overt and subclinical disease, supported by trial evidence on when treatment helps. A starting dose justified by weight, age and cardiac status, teaching on timing and interactions with calcium, iron and acid suppressants and a defined schedule for TSH checks show safe prescribing. Attention to the risks of overtreatment, including atrial fibrillation and bone loss after menopause, shows complete management. Explaining why T3 is not added and what to check if fatigue persists shows judgment beyond the dose. Including advice on bone health after menopause rounds out the plan.
NUR 7072 Module 5 help: mistakes that cost marks
Thyroid papers often start levothyroxine for any high TSH. Repeat the tests, check free T4 and say whether the disease is overt or subclinical. Use trial evidence to explain when treatment helps, choose a starting dose for the patient's weight, age and heart and teach timing and interactions. Plan the first TSH check and how you will adjust the dose, and explain why overtreatment is also harmful. Share your module prompt and the laboratory results; a matching free first draft will follow. Explain what you would check if symptoms persist with a normal TSH. Mention bone and heart effects of overtreatment so the target makes sense.
Write yours, or have the desk draft it
This paper is an original model document written by our desk, not a submitted student paper and not an official Thomas Edison State University document. Read it for the moves, then write your own to the instructions in your classroom. If you want one built to your exact prompt and rubric, the first custom sample is free and arrives in 24 to 48 hours.
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NUR 7072 Module 5 questions, answered
Where can I find a free NUR 7072 Module 5 sample paper?
The overt hypothyroidism case paper, from diagnosis to a six-week TSH check, is available here.
How is overt hypothyroidism different from subclinical?
In overt disease free T4 is low as TSH rises; in subclinical disease TSH is raised but free T4 stays in range.
Should older adults with subclinical hypothyroidism be treated?
In the TRUST trial, a year of levothyroxine left symptom and fatigue scores no better than placebo in people 65 and over.
How should levothyroxine be taken?
On an empty stomach, an hour before breakfast or at bedtime, separated from calcium and iron.
When should TSH be checked after starting levothyroxine?
At four to six weeks after a new start or dose change, per the ATA guideline.