Discussion: Manifestations of Depression

Discussion: Manifestations of Depression

Reply to Amanda

Do you take any medications?

Some medications (Lithium) are notorious for causing hypothyroid.

Have you ever been diagnosed with a thyroid disorder?

Surgeries to the thyroid may result in hypothyroid.

Are you allergic to anything?

Relevant to treatment regimen.

Have you experienced any significant life changes? Additional stress etc?

Depression may manifest similar symptoms.

PE:

Hypothyroidism is six times more common in women than men, and is most common in older women (Carson, 2009). A thorough physical assessment should be completed. Clinical signs and symptoms may include paleness, brittle appearing hair and skin, elevated blood pressure, and bradycardia (Carson, 2009). The patient may have a “puffy” appearance to her face, irregular periods, and report sustained fatigue (Roberts et al, 2009).

Differential Diagnoses

Anemia, Depression

Diagnostics

TSH – Will be elevated in Hypothyroid

Free T4 – Result will be low in Hypothyroid

Cholesterol – Often elevated with Hypothyroid

CBC – To rule out anemia

CMP – To monitor other electrolytes

EKG – to assess for any blocks, prolonged QRS, or electrolyte abnormalities

Treatment

Patients with symptomatic hypothyroidism should be treated to prevent long-term complications (Roberts et al, 2004) Depending on the results of her TSH & T4 I would initiate a daily regimen of Levothyroxine. 4-6 weeks after the initiation of Levothyroxine I would recheck the patients TSH. After the TSH has reached a therapeutic level – I would recheck it again in 6 months.

References

Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing Standard (through 2013), 23(18), 48-56; quiz 58. Retrieved from

Roberts, C. G. P., & Ladenson, P. W. (2004). Hypothyroidism. The Lancet, 363(9411), 793-803. doi:http://dx.doi.org/10.1016/S0140-6736(04)15696-1

reply to Quiana

1. What additional questions should you ask the patient and why?

Some questions include:

• How much weight has been gained? What kinds of meals/foods do you typically take? Do you exercise?
• Quantifying the amount of weight provides perspective. A gain of 5 lbs does not carry the urgency that a 20 lb weight gain does. Asking about her lifestyle habits can offer some insight into factors that can aggravate what sounds like hypothyroidism. This creates teachable opportunities for improving lifestyle habits.
• Are you still menstruating and if so, how regularly?
  • This can rule out pregnancy or hormone changes that precipitate menopause. Also, with hypothyroidism, this condition can disrupt a normal menstrual cycle. For a woman in menopause, hypothyroid symptoms can be masked or ignored when it is assumed that it is a lack of ooestrogen that is causing her concerns (Baisier, Hertoghe, & Eeckhaut, 2000).
• Bowel habits, specifically any problem with constipation?
  • (Chaker, Bianco, Jonklaas, & Peeters, 2017)
• Any hx of depression?
  • Her reported complaints are common findings for hypothyroid but they can also be related to depression. Though the rate of depression in hypothyroid patients is >60% (Bathla & Singh, 2016), the patient should be screened for depression. Her symptoms could be psychosomatic.

1. What should be included in the physical examination at this visit?

• Included items to address are skin for dryness, hair for thinning or irregular growth pattern, eyes for exopthalmus, neck/throat and thyroid for possible goiter, cardiac sounds for bradyarrhythmias, and also for peripheral manifestations like delayed relaxation of deep tendon reflexes (Chaker, et al., 2017).

1. What are the possible differential diagnoses at this time?

• Hypothyroidism
• Depression
• Anemia
• What tests should you order and why?
• TSH and free T3 and T4
• EKG
• CMP
• CBC
• Lipid Panel
• A depression screen can be done in office

Hypothyroidism can increase lipids and alter cardiac function (Chaker, et al., 2017). EKG may reveal cardiac abnormalities. CBC can reveal anemia. The metabolic panel can reveal diabetes or problems with hepatic or renal function. Hypothyroidism continues to be researched as far as the specific link to renal and hepatic dysfunction (Chaker, et al., 2017). The depression screen serves, like the other lab orders, to exclude causes of her symptoms. The most obvious test is a thyroid panel. To assess the circulating amount of hormone in the body is to judge her thyroid function. Discussion: Manifestations of Depression.