Mr. T, a white man aged 51 years, presented to a free clinic for management of hypertension and to obtain prescriptions. Although he had insurance through the U.S. Department of Veterans Affairs (VA), Mr. T stated that he felt safer coming to the free clinic.

Mr. T had previously obtained medications through a variety of free clinics but was looking for a location where he could receive regular care. With a history of homelessness, substance abuse and mental illness, Mr. T thought the free clinic would be a good solution. He reported no other comorbidities, family history or past medical issues. He stated that his hypertension was well managed with a 
two-drug regimen.

After several visits, the clinic staff members noted that Mr. T’s pulse and BP fluctuated drastically. He was on a beta blocker to manage hypertension, but he also reported consuming at least two pots of coffee per day. Additionally, Mr. T stated that he had increased anxiety when he came to the clinic because there he would see people with whom he had previously used drugs. 

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Mr. T routinely refused laboratory evaluation and would not return for follow-up appointments with any regularity. Given his nonadherence 
to medication and follow-up, the providers began to question other causes of his tachycardia and hypertension, notably extreme anxiety and possibly substance use.

1. History

Mr. T’s history indicated polysubstance abuse and increased anxiety, with self-diagnosed 
panic attacks that occurred weekly. Mr. T reported attending Narcotics Anonymous meetings several times per week. He noted previous attempts to cut down his caffeine consumption but found that his anxiety continued.

Mr. T was previously homeless but was working in sales at the time of his appointment. He reported no current use of alcohol or illicit drugs but admitted to smoking one to three 
packs of cigarettes a day, depending on his anxiety level. Mr. T also 
reported taking metoprolol (Lopressor, Toprol) 50 mg b.i.d. and hydrochlorothiazide 25 mg once daily for treatment of hypertension. 

2. Examination

On presentation, Mr. T appeared anxious. His speech 
was rapid, he displayed minimal eye contact during consultation, and he tapped his feet throughout the visit. 

The patient’s BP was mildly hypertensive (145/82 mm Hg), and his pulse was 68 beats per minute. Mr. T’s BMI was 20.87. 

Head and neck exam were unremarkable, lung sounds were clear, and heart rhythm was regular without extra sounds. An abdominal exam was also unremarkable with normoactive bowel sounds. No peripheral edema was noted. 

3. Laboratory Data and Diagnosis

After a lengthy discussion, the patient agreed to venipuncture. Given Mr. T’s history of polysubstance abuse, and his anxiety symptoms, the providers doubted he would return for additional testing. Thus, a battery of tests were ordered, including a lipid panel, hemoglobin A1c, a complete blood count and comprehensive metabolic panel, and several thyroid tests (triiodothyronine [T3], thyroxine [T4], and thyroid-stimulating hormone [TSH]).

All labs returned within normal limits except for the thyroid studies. Mr. T’s total T3 was 481 ng/dL (normal 80-175 ng/dL), total T4 >30.0 µg/dL (normal 4.9-12 µg/dL), and TSH <0.01 mIU/L (normal 0.3-5.50 mIU/L).

Given these results, Mr. T was sent for a thyroid uptake study. The 24-hour uptake was 59%, which was well above the normal range of 7% to 30%. Hyperthyroidism, specifically toxic diffuse goiter with mention of thyrotoxic crisis or thyroid storm, was diagnosed. 

4. Treatment

Endocrinology was consulted, and Mr. T was started on methimazole (Tapazole) daily in addition to his metoprolol. Within a week, the patient noted decreased anxiety, and his BP and pulse began to normalize. The endocrinology team recommended that Mr. T continue the current regimen for one year with close follow-up. The patient understood all this and agreed to comply. 

5. Discussion

There are many challenges associated with providing health care to homeless or unstably housed individuals. The health of homeless individuals can be influenced by increased exposure to communicable disease, increased prevalence of psychosocial problems, and limited or fragmented access to health services.

In addition, stress, lack of access to healthful food, chemical dependency, and mental illness can result in an increase in chronic disease.1 A lack of continuity in their health care, nonadherence to treatment, and low literacy can further complicate the health and well-being of the individuals.2 The symptoms of a homeless patient presenting for care can be complicated by the fact that these symptoms can be caused by both medical and psychological disorders, and careful evaluation needs to be completed.3

Mr. T initially presented to the clinic with a history of polysubstance abuse, untreated anxiety and consumption of significant amounts of coffee. His hypertension was being treated with metoprolol and hydrochlorothiazide, while other health-care concerns were being managed at the VA hospital. Unfortunately, Mr. T had lapses in care for long periods of time.

Following recommendations for the care of homeless patients,4 a comprehensive and ongoing history was obtained at each clinic visit. Mr. T’s physical exams, while normal, did elicit tachycardia, which he explained was the result of his anxiety and walking to the clinic. His caffeine consumption also explained his tachycardia symptoms, as overconsumption can lead to cardiac side effects. While hyperthyroidism, anxiety and substance abuse should be differential diagnoses when a patient presents with caffeine intoxication,5 Mr. T’s refusal of baseline labs and the medical management of his hypertension complicated and delayed his diagnosis for more than one year. 

Typical symptoms of hyperthyroidism include tachycardia, increased BP, nervousness and anxiety — all of which were reported by this patient. These same symptoms are typically seen in individuals with untreated anxiety, an overconsumption of caffeine, polysubstance abuse and hypertension.

Furthermore, Mr. T’s hypertension (and treatment with a beta blocker) complicated this diagnosis because it masked many of the symptoms associated with hyperthyroidism. The beta blocker lowered his BP and kept his heart rate at a level that wasn’t a concern. Because, Mr. T had declined treatment for his anxiety, it was not known what symptoms would have persisted had his anxiety been adequately managed.

6. Summary

Mr. T’s hyperthyroidism was masked by excessive caffeine consumption, a history of untreated anxiety and polysubstance abuse, and the lack of prominent physical signs of hyperthyroidism. In addition, Mr. T’s long-term treatment for his hypertension controlled his palpitations, tachycardia, tremors and anxiety, which further delayed the diagnosis.6

There are conflicting guidelines regarding screening for hyperthyroidism. The U.S. Preventive Services Task Force concludes that the evidence is insufficient to recommend for or against routine thyroid-disease screening in adult patients.7 The American Association of Clinical Endocrinologists recommends screening older patients, especially women, but age is not specified.8 The American Thyroid Association recommends TSH testing for women and men older than age 35 years and every five years thereafter.9 The American Academy of Family Physicians recommends routine screening for all individuals aged 60 years and older.10

TSH screening is supported for people with a history of: autoimmune disease; pernicious anemia; neck radiation (potentially affecting the thyroid gland); thyroid surgery; abnormal thyroid examination; psychiatric disorders; amiodarone (Cordarone, Pacerone) or lithium (Lithobid) maintenance; and ICD-9 diagnoses that support TSH testing (i.e., anemia, constipation, dysmenorrhea, hypercholesterolemia, malaise and fatigue and weight gain).11

Considering his history of anxiety, Mr. T should have been screened for TSH and diagnosed with hyperthyroidism. Mr. T’s hyperthyroid condition might have been caught at an earlier stage if he had been adequately housed and accessible to medical personnel (provided that appropriate lab work had been obtained and follow-up care utilized).

Unfortunately, those who are homeless and precariously housed typically experience ongoing health complications and a worsening of existing health problems. They are at increased exposure to communicable diseases, live in dangerous and unsanitary environments and have limited access to care.1

Furthermore, their chronic conditions are exacerbated by poor nutrition, high stress, substance abuse, behavioral health issues and limited access to and safe storage of medications.12 Other barriers to care for those who are homeless include the lack of continuity of care, lack of health insurance, perceived discrimination and provider bias, issues in patient-provider trust and communication difficulties.2, 13, 14

It is of utmost importance that health-care providers be aware of the complex factors faced by inadequately housed patients. Clinicians must find a way to establish a trusting relationship with this very vulnerable population.

April Bigelow, PhD, ANP-BC, Chin Hwa Dahlem, PhD, RN, NP-C and Michelle Pardee, DNP, FNP-BC, are clinical assistant professors at the University of Michigan School of Nursing in Ann Arbor.


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All electronic documents accessed August 15, 2013.