(BOMS4004)

WESTERN INTERNAL MEDICINE

Case Report: Thyroid Disease

Name : NG JING WEN

Student ID : B200037A

Class : BTCM20-A

Lecturer : Dr. Liew Zhi Hao

Bachelor of Traditional Chinese Medicine

Southern University College

2nd Semester 2023

 Name: Lily Tan

IC No.: 690114-02-8384

Age: 54

Gender: Female

Visit’s 2/9/2023
Date:

No.: 10001

Chief Complaint:

Fatigue, weight gain, and cold intolerance for three months.

History of present illness:

Lily presents with a three month of increasing fatigue, loss of appetite, unexplained weight
gain of 5kg, and sensitivity to cold. She also reports that she is having dry skin and hair,
constipation, and a hoarse voice. Pulse thin and weak, light red tongue with thick white coat,
and tongue marks.

Past history:

Lily has no significant past medical history, does not had any surgery before, and has not
been on any long-term medications.

Family history:

No known family history of thyroid disease.

Personal history:

Work as a school teacher. Married with three children. She is non-smoker but generally
occasional social drinker.

Gynaecologic history:

Regular menstrual cycles. No history of gynaecological disorders. L.M.P: 20/8/2023

Sexual history:

No sexual dysfunction reported and no sexual intercourse recently.

Clinical examination:

1. Vital Signs:

Blood Pressure: 120/80mmHg

Heart Rate: 70beats/min
Respiratory Rate: 16 breaths/min
Temperature: 37℃
SpO2 95% on Room Air

2. Inspection:

Dry skin and brittle nails, mild puffiness around the eyes, goiter not palpable.

Investigation:

1. Full Blood Count (FBC): Hb 13g/L, Platelet 350*109/L, HCT 40%, WBC 15*109/L
2. Thyroid Function Tests: TSH 5.5mU/L, FT4 8pmol/L

Diagnosis:

Primary Hypothyroidism (due to autoimmune thyroiditis – Hashimoto’s thyroiditis)

Treatment (Western Medicine):

1. Started on Levothyroxine replacement therapy to normalize thyroid hormone levels.

2. Advised on regular follow-up and medication adherence.
3. Recommended of lifestyle modifications which include balanced diet and exercise.

Treatment (Traditional Chinese Medicine):

From the symptoms of this patient, it shows a Qi deficiency syndrome of hypothyroidism.

TCM prescription that are used for her are BuZhongYiQi Decoction Variation. The herbs
medicine inside this prescription are HuangQi, RenShen, BaiZhu and so on. It has the action
of tonify and regulate Qi, strengthen the spleen, and regulate metabolism. This prescription
can be combined use with the Levothyroxine. Prognosis of her include acupuncture and
moxibustion. It can help in regulate the circulation of Qi and blood, promote balance in the
body, alleviate fatigue and aid in weight management.

Doctor’s advisor (TCM):

Patient should closely cooperate with TCM practitioners and Western medical doctors
undergo follow-ups and examinations to ensure treatment effectiveness. TCM treatment
typically used as complementary therapy and should not replace conventional treatment
methods such as thyroid hormone replacement therapy. Advised to maintain a regular
lifestyle which including adequate sleep, moderate aerobic exercise, and emotional
management are very important.