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When treating the whole patient bears fruit

Pain is a very subjective symptom. So when my patient first presented with a request for more painkillers, I complied...

Dr Samia Bushra's article was judged 'highly commended' in our clinical writing competition.

Pain is a very subjective symptom. So when my patient first presented with a request for more painkillers, I complied.

He was around 50 years old, Caucasian, six-feet tall and a bit overweight. It was a Friday evening and he had been given a prescription of gabapentin for ‘facial pain' by his neurologist, but had failed to pick it up at the hospital. In addition, he wanted his usual painkiller – codeine plus paracetamol. He was almost in tears. I issued a script and asked that he book an appointment for follow-up.

Over the next few months I got to know him better as a patient. He had had this pain for the past two years and it was gradually increasing, causing him to finally seek medical help a year before. His previous GP had referred him to hospital when nothing worked. Other causes of facial pain, including dental and maxillary surgical causes, had been investigated and ruled out. I decided to review and repeat his blood tests.

They were all reported as ‘normal', but I noted that his TFT was somewhat borderline. I did not have previous bloods to compare, but his TSH was at the upper limit of normal.

At the time, I also tried to address lifestyle changes. One problem was an ongoing knee pain that he claimed stopped him from losing weight. His knee examination was normal.

After excluding other causes for ongoing pain – and checking on time off work, home stresses and psychiatric illness – I repeated his TFTs and requested a thyroid antibody test. Repeated TSH was always above 5.6 and his thyroid antibodies were high. This was a man who still worked regularly and was only attending the surgery for his pain relief.

Wide-ranging effects

The thyroid gland affects the metabolism of muscles and nerves. It is widely known for ‘weight gain' and ‘feeling tired', but is also a cause of both polyneuropathy and mononeuropathy, and in long-standing hypothyroidism has been shown to cause patchy demyelination of nerves. It also causes myopathy, which in long-standing hypothyroidism manifests as weakness, decreased muscle reflexes and pain.

The advantage of being a GP is that one is able to see the patient as a whole, and so determine whether only reassurance is needed or the patient should have further investigation and treatment.

I decided he needed further assessment. I discussed the blood results with him and the fact that so far nothing had been found to explain his symptoms of pain. The blood results were within the normal range, but ‘normal' differs for each individual. So theoretically if his ‘normal' TSH used to be 1 or 2, he could have been gradually becoming hypothyroid and exhibiting symptoms.

He agreed to start on a low dose of thyroxine. I explained the symptoms of over-treatment and in the following few months monitored his response and blood levels of TSH and T4. It took up to a dose of 100µg of levothyroxine for his TSH to come down to around or below 2. He himself said he was ‘feeling so much better'.

His knee pain, although still an occasional problem, had not stopped him from being active and taking up a sport. His ‘thick ankles' were actually partly a result of hypothyroid swelling of the lower limbs.

My focus on getting his levels of TSH adequate and his enthusiasm for lifestyle change meant we forgot about his original complaint – facial pain. He had gradually stopped all his painkillers and gabapentin and was actually pain free.

Dr Samia Bushra is a GP in Dagenham, east London

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Readers' comments (6)

  • You are a credit to your profession, Dr. Bushra. Too many GPs and endocrinologists treat the TSH number and ignore the symptoms when TSH is within lab reference range. I hope you are a GP Trainer.

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  • I agree with the previous comments. All too often patients are treated as numbers on a register,who in turn have to "jump through the hoops" to achieve "normal"blood test numbers not as people with appalling symptoms needing expertise and experience to get rid of these. If only GPs had the time and inclination to look at the whole patient,including non-medical history,to help. Time and money,never mind suffering,could be saved in the long-term.

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  • What a great GP you are! Hypothyroidism causes so many diverse and unpleasant symptoms, but lots of doctors leave patients symptomatic and under treated as their TSH is "in range". Far better in fact to go by symptoms (or fT3 and fT4 levels if blood tests have to bd used).

    In my case, and that of many other patients, levothyroxine was not the answer on its own, and I needed the addition of some direct T3 in order to eliminate my symptoms.

    I have a fantastic GP who does go by symptoms and who prescribes me the Armour Thyroid which makes me feel well. I wish there were more like these two.

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  • Please could GP's treat by symptoms, weight gain, exhaustion, low body temps, joint and muscle pain, blurred vision, swelling of eye lids, non pitting oedema in the ankles, not being able to pinch up skin?

    There is so much suffering with patients not being diagnosed, or being under-treated. There's a lot of research now that each individual has his/her own set point where the thyroid is concerned. How many patients do you see with "normal" bloods, but still symptomatic? I've heard it all, thyroid antibodies don't matter, it can't be your thyroid because you are "in range"

    Many patients get this treatment even from Endocrinologists. There seems to be a deep learning curve needed by the medical profession to make themselves "thyroid aware" and a levothyroxine tablet simple does not cure everything for a huge number of patients.

    I am finding myself in the awful position of buying thyroid drugs I need online. Levothyroxine didn't work in the two years I took it. I am improving on Armour thyroid and Cynomel. These treatments should be made freely available.

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  • So encouraging to come across a GP who listens to her patients and makes a diagnosis based on symptoms, not just the 'holy' TSH. I wonder where she trained? Am willing to bet it wasn't this country.

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  • I was lucky to be diagnosed quite quickly after blood tests, and prescribed Levothyroxine slowly until I reached my correct readings. What if I had'nt because of all the horrible symptoms I had if my bloods had not come back off the scale of what the average reading should be I may have been prescribed painkillers or worse antidepressants and still have all the symptoms to deal with, which seems to be the case with some people.

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