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Hypothyroidism (E 03.9) Positive findings: weight gain, lack of energy/fatigue, worsening of depression, HTN, brittle hair, cold intolerance, dry skin, constipation, muscle cramping in b/l LE, family history of autoimmune disease Negative findings: no enlarged thyroid gland, bradycardia, no episodic neck pains and/or sore throat Laboratory findings: TSH 770 uIU/mL high FT4 62 ng/dL low TRH secreted in hypothalamus stimulates the pituitary gland to produce TSH which, in turn, stimulates the thyroid gland to produce and secrete mainly T4 (approximately 100-125 nmol daily) and smaller quantities of T3. Levels of T3 majorly and T4, to some extent, in turn, exert negative feedback on the production of TRH and TSH. Alteration in the structure and function of any of these organs or pathways can result in hypothyroidism. In overt hypothyroidism, TSH levels are elevated, and free T4 levels are low. (Patil, 2019). RBC 4.44 x 10E6/uL normal result Hemoglobin 14.0 g/d normal result Hematocrit 2% normal result These results rule out diagnosis of anemia. PHQ-9 Depression Score is 10 compared to previous that was 5 (mild depression) about 6 months ago meaning that the patient has progression of depression – 10 to 14 points is considered moderate depression (Maurer, 2018). Medication Synthroid 131 mcg, PO Disp # 30 tablets Sig: 1 tablet daily RF: 0 Hypothyroidism is mainly treated with Levothyroxine monotherapy. Levothyroxine sodium tablets contain synthetic crystalline L-3,3′,5,5′-tetraiodothyronine sodium salt – levothyroxine (T4) sodium. Synthetic T4 is identical to that produced in the human thyroid gland. Replacement Levothyroxine dose is 1.6 mcg/kg per day; however, in elderly and atrial fibrillation patients, it is important to reduce the dose. For better absorption Levothyroxine should be taken 30-45 minutes before breakfast and at least 3 hours post-meal; some patients prefer at bedtime. Some medications (PPI) and supplements such as calcium (the patient is on Calcium 500 mg. supplement), magnesium do affect the absorption of Levothyroxine. Labs should be drawn every 4 to 8 weeks until target levels are achieved after starting the treatment. Patients with cardiac disorders should monitored for angina and atrial fibrillation (Patil, 2019). Prozac 40 mg, PO Disp # 30 tablets Sig: 1 tablet daily RF: 1 The patient is on Prozac 20mg for depression. Based on PHQ-9 Depression Score, she would probably need increase in dose of this medication. Fluoxetine has FDA-approval for major depressive disorder. Low levels of serotonin and norepinephrine appear in the cerebrospinal fluid of patients with depression. Fluoxetine exerts its effects by blocking the reuptake of serotonin into presynaptic serotonin neurons by blocking the reuptake transporter protein located in the presynaptic terminal. The initial antidepressant effect emerges within 2 to 4 weeks, so I would assess the patient in 6 -8 weeks (Sohel, 2021). Patient education Instruct the patient about a life-long therapy review symptoms of hypothyroidism (lethargy, fatigue, cold intolerance, constipation, weight gain, dry skin) and hyperthyroidism (nervousness, palpitations, insomnia, tremor) educate on compliance with medication – family members help may be needed patients with psychomotor symptoms may need to refrain from operating the machinery or vehicle until the symptoms have resolved the same brand of thyroid preparation is recommended ferrous sulfate, sucralfate (Carafate), antacids or mineral supplements may slow Levothyroxine absorption through GI tract – teach to take Synthroid 2 hrs. before or 4 hrs. after these medications Consume low fat and high fiber diet seek immediate medical attention in case of cardiac or respiratory difficulty BP monitoring (Durphy, 2019) Referral After starting Levothyroxine therapy, the treating physician should monitor the effect of therapy for 4 to 8 weeks by assessing TSH levels to determine if dose adjustment of Levothyroxine is needed. The target TSH level is 0.3 to 2.4 mIU/L. A referral to an endocrinologist is necessary if the patient has heart disease, symptoms of myxedema, or central (secondary or tertiary) hypothyroidism. After starting hormone replacement therapy, if signs or symptoms of myxedema, chest pain, or thyrotoxicosis appear, you should contact an endocrinologist (Dunphy, 2019). No referral needed at this time. Current problems are: Depression, HTN, Hypothyroidism, Obesity, Constipation, Lack of energy, Cold intolerance, Muscle cramp, Postmenopausal Osteoporosis, Allergy to Iodine dyes, Skin xerosis I would recommend checking BP regularly and reporting if the numbers are high so I can increase her current medication, Bisoprolol-HCTZ 2.5mg/6.25mg. In patients whose blood pressure is not adequately controlled at the initial dose, subsequent titration (at 14-day intervals) may be done with ZIAC tablets up to the maximum recommended dose of 20/12.5 mg (phactmi.org, 2022). Constipation. Bowel habits, activity, and dietary intervention – should be instructed to slowly increase the amount of dietary fiber to 25 to 35 grams per day, with at least 12 to 15 grams at breakfast. If requires pharmacological intervention, can use pharmacological OTC medication for short term (Dunphy, 2019). Dry skin. Recommend moisturizers for dry skin. References Dunphy, L. M. (2019). Primary Care: Art and Science of Advanced Practice Nursing – An Interprofessional Approach (5th Edition). F. A. Davis Company. https://bookshelf.vitalsource.com/books/9780803694941 Maurer, D. M., Raymond, T. J., & Davis, B. N. (2018). Depression: Screening and Diagnosis. American family physician, 98(8), 508-515. Patil N, Rehman A, Jialal I. Hypothyroidism. [Updated 2022 Feb 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519536/ Sohel AJ, Shutter MC, Molla M. Fluoxetine. [Updated 2021 Jul 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459223/ (Links to an external site.) https://www.phactmi.org/search Reply discussion post.

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