The primary diagnosis for this patient at this time is hypothyroidism

Peer response substantively to at least one topic-related post of a peer including evidence from appropriate sources
Peer post-
The 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).
Problem List
Hypothyroid state
Depression
Generalize Fatigue
Overweight
Constipation
Cold intolerance
Muscles cramping
F/U plan, referral, and changes
I will ask the patient to come back in 6 weeks for a reevaluation of the treatment. If symptoms become worse prior to the scheduled appointment, then I will ask the patient to come in sooner. At this time patient does not need an endocrinologist consult but, in the future, if the patient encounter myxedema crisis or coma or new onset of cardiac issue, or for secondary or tertiary hypothyroidism, or difficulty achieving euthyroid state then I will refer the patient to an endocrinologist and cardiologist (Hollier A., 2021)
Currently, I will not change her medication regimen, even though the patient’s PHQ9 depression score is 10. The reason is that hypothyroidism does increase depression symptoms. I do not want to over-treat the patient. Therefore I will assess the patient again in her next visit for depression, and make my decision on whether to increase her Prozac dose or refer her to a psychiatrist. Currently, the patient should continue taking all of her regular medication including B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg + Vit D3 400IU as prescribed. I will ask her to hold multivitamin due to biotin interference with TSH, T4, and T3 levels (ATA, 2018). Additionally, the patient demonstrates an elevation in her DBP. I will advise the patient to check BP regularly unless she notices a significant increase in BP then advise her to either call the provider or go to the nearest emergency room. However, elevation in DBP can happen due to the patient’s hypothyroid condition. After 6 weeks I will reassess her BP and make changes accordingly (Polat, et al, 2017).