Holy f***. This example is definitely going to be up there in terms of how egregious it is. Literally, this is first- or second-year medical student level knowledge. Hell, even a pre-med biology major could answer this. Does NP Niki know that TSH = thyroid STIMULATING hormone? Even a layperson with a few brain cells to rub together could infer that if your thyroid STIMULATING hormone is low then that probably means you've already got enough thyroid hormone. And does NP Niki know that levothyroxine is synthetic T4? And that a free T4 of 2.7 is high? So maybe try lowering their levothyroxine dose for starters? In any case, the fact that this patient is status post thyroidectomy means that they should have been referred to an endocrinologist yesterday, instead of having a midlevel NP who apparently has little to no clue how the hypothalamic–pituitary–thyroid axis works play around with their hormones. There's a reason why endocrinology is a two or three-year fellowship (after three years of internal medicine residency!) Sweet Jesus indeed!