Dear Colleague,

Case Challenge #8: Same Thyroid Medication. Different Results. What Changed?

“I’m taking it every morning. Why do I feel like I’m going backward?”

A 52-year-old woman returns with fatigue, constipation, and increasing sensitivity to cold.

For two years, she felt well on levothyroxine 100 mcg daily. Her TSH remained stable.

Now, her results have changed:

She reports no missed doses. Her weight and medication manufacturer are unchanged.

But four months ago, she began treatment for iron deficiency and added a calcium supplement.

To avoid forgetting anything, she now takes her thyroid medication, iron, and calcium together with water when she wakes up, then waits an hour before breakfast.

“I thought I was doing everything right,” she says. “Do I need a stronger prescription?”

What is the best next step?

A. Recommend increasing levothyroxine because the elevated TSH establishes that her prescribed dose is no longer sufficient.

B. Recommend increasing levothyroxine and separating the supplements at the same time to address both possible causes immediately.

C. Coordinate with her prescribing clinician to address the medication–supplement timing and plan reassessment before assuming she needs a higher prescribed dose.

Before you reveal the answer, choose A, B, or C—and identify the finding that most influenced your decision.

Could you explain your next step to this patient?

See which finding changes the next step—and compare your reasoning with the case explanation.

REVEAL THE ANSWER & COMPARE YOUR REASONING →

Become the Clinician Who Can Explain What Comes Next—and Why.

Identifying an abnormal result is one skill. Explaining what deserves attention next—and why—requires clinical reasoning. 

This case gives you an opportunity to practice that decision. 

FMU helps you become a more confident clinical thinker—one who can explain what deserves attention next and why.

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Warmly,

Ron Grisanti, D.C.
Founder, Functional Medicine University

P.S. This case gives you one opportunity to practice clinical reasoning. 

Develop that skill further with FMU’s comprehensive functional medicine education and advanced clinical sequencing. 

Enroll in October to receive both additional certification training programs at no extra tuition charge—the final enrollment opportunity with both included.

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