Peer postThe primary diagnosis for this patient at this time is hypothyroidism (E03.09) (ICD10 data.com, 2022). The CBC results are normal which can r/o diagnosis of
anemia. The PHQ-9 score is higher this time than the previous visit. However, hypothyroidism presents with similar symptoms of depression, therefore, I will
support my diagnosis with the patient’s pertinent positive and negative symptoms.
The patient’s pertinent positive subjective findings are generalized constant fatigue in spite of enough rest, constipation, cold intolerance, 5 lb weight gain in
the last 6 months, intermittent muscles cramping in calves. The patient’s pertinent positive objective findings are blood test results of TSH 6.770 uIU/mL,
(normal 0.5 to 5.0) and FT4 0.62 ng/dL(normal -0.7-1.9) Results of low FT4, and elevated TSH suggests that the patient’s thyroid gland is not releasing
sufficient thyroid hormones, therefore TSH is high. Additionally, her increasing age, and being a woman can contribute to hypothyroidism. . As per American
Thyroid Association(ATA) women are five to eight times more likely than men to have thyroid problems. Additionally, her PE demonstrates mild diastolic HTN
(146/95) dry skin, coarse and thick hair, and 1+ (diminished) knee and ankle reflexes. All of these symptoms are suggestive of hypothyroidism.
The patient’s pertinent negative subjective symptoms are that she denies pain, denies changes in the skin, hair, or nails, no family hx. of hypothyroidism. The
patient’s pertinent negative objective findings are a supple neck, no lymphadenopathy, the thyroid is midline, small, and firm without palpable masses. All of
these symptoms strongly suggest hypothyroidism.
Treatment plan
The initial primary hypothyroidism should be treated by oral T4 monotherapy (levothyroxine sodium). The research showed that early initiation of
Levothyroxine therapy significantly improved the TSH level, and symptoms related to hypothyroidism. Levothyroxine also reduced the risk of ischemic heart
disease, and mortality (U.S. preventive service task force (USPSTF), 2017).
I will prescribe the following medication
Allergies: Iodine dyes
Levothyroxine 12.5mcg
Disp # 45
Sig: Take one tab by mouth daily on empty stomach.
Indication for use: for Hypothyroidism (Epocrates, 2021)
Refill: 5
Signature: Purvi Shah
Further Testing
At this time no other diagnostic testing is necessary other than the initial blood test for TSH and FT4. I will ask the patient to come in 6 weeks for another
blood test to measure the effectiveness of the initial treatment. The treatment goal is to normalize TSH concentrations, resolution of physical and mental
complaints, and avoid undertreatment or overtreatment (Chaker L, Bianco A.C, Jonklaas J., Peeters R.P.,2017). After 6 weeks If the patient’s lab results
suggest any further testing is required then I will order a thyroid antibody, which can help me r/o Hashimoto’s thyroiditis (Croswell J. 2015).
Patient Education
I will educate the patient to take medication as prescribed and take it on an empty stomach, 30 minutes prior to a meal or 3 hrs. after a meal. Wear an extra
layer of clothing if the patient feels cold, do not use hitting pads to stay warm. I will educate the patient and family that hypothyroidism needs lifelong therapy
and periodic blood work to monitor treatment efficacy. Also, If a patient develops nervousness, palpitations, insomnia, or tremor, educate the patient to call
the provider or go to the nearest emergency room (Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. 2019). Additionally, inform the patient that it will
take 1 to 2 weeks for the medication to work. Moreover, patients with hypothyroidism become more sensitive to certain medications therefore take caution
on taking analgesics and sedatives, even in small doses, these medications can cause severe somnolence and respiratory depression. Take low-fat, and
high-fiber foods, increase water intake to six to eight glasses a day to reduce constipation. A low-fat diet is recommended because there is a high incidence
of atherosclerotic heart disease in patients with hypothyroidism (Dunphy, L. M., Winland-Brown, J., Porter, B., & Thomas, D. 2019). Most importantly I will ask
the patient to stop taking multivitamins for now because multivitamins typically contain 30-300 mcg of biotin which can result in falsely high levels of T4 and
T3 and falsely low levels of TSH, leading to either a wrong diagnosis of hyperthyroidism or that the thyroid hormone dose is too high (American Thyroid
Association (ATA), 2018)