Concluded Case

Hyperthyrodism wt. 47.5 kg ht. 5.3" BMI 18.6

Dr. Sepuri Krishna Mohan Dr. Sepuri Tirumala Devi Dr. Ajeet Singh Respected sir n ma'am kindly suggest Rx n Dx Is it associated with antipsychotic drugs Chief Complaints 55 y/f c/o weakness , giddiness since 1 month History P/h 2yr back diagnosed with hyperthyroidism with ?toxic mng with Tsh less than 0.008 treated by endocrinologist neomercazol 10 mg Hs n then 15 mg hs along with shelcal 500 mg bd ciplar la 20 mg bd. Her tsh is normalised along with ft3 n ft4 she took treatment 1 yr She is also k/c/o depression disorder n on treatment since 15 yr she is taking present treatment etizolam 0.5 mg hs and paroxetine 12.5 mg hs and betacap tr 40 mg in morning Vitals B.p 122 /78 Hr 82 /min Temp. 97.8 F Diagnosis Hyperthyrodism Lab Report Recent reports cbc s.e. lft kft tft rbs are attached TSH less than 0.004 FT3 8.07 {2.3 -4.2 } FT4 3.52 0.89 -1.76 }

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As far as your case is concerned, you are right she is a case of hyperthyroidism. Decreased levels of TSH with elevated T4 points towards Hyperthyroidism. She has been feeling giddy and weak due to her hyperthyroidism aggravating as evident by TSH decreasing further from 0.008 to TSH 0.004, so she needs dose adjustment as of now. Please order an anti-TPO Abs for her and ask her to do Free TFT every 3 months to check her thyroid status and dosage adjustment. Also hand over a Hospital Anxiety and Depression Scale (HADS), and ask her to fill it up, which will give you an idea about whether it is anxiety or depression. I use it quite frequently in my OPD. For her hyperthyroidism with depression you can put her on - 1) Tab. Carbimazole 20mg BD, and later can down titrate slowly upon next thyroid report, 2) Tab. Propranolol - LA 20mg BD is good enough, or if needed can go to 80mg/day or so, Please check exopthalmos status, is severe and having dry eye problem, you can prescribe her artifical tear drops like refresh tear 0.05%, and advise for taping the eye at night. Regarding depression, put her on Sertraline, start with 25mg OD for 6 days, and then escalate the dose to 50mg OD in morning for 6 months. If she needs etizolam 0.5mg at night, you can prescribe her a combination of etizolam 0.5mg plus propranolol 20mg at bedtime, instead of plain propranolol as advised above. I hope this will help you out to deal with this case. Another expert opinion on depression with hyperthyroidism can be given by respected sir @Gunjesh Kumar . Would love to hear from you sir.

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As far as your case is concerned, you are right she is a case of hyperthyroidism. Decreased levels of TSH with elevated T4 points towards Hyperthyroidism. She has been feeling giddy and weak due to her hyperthyroidism aggravating as evident by TSH decreasing further from 0.008 to TSH 0.004, so she needs dose adjustment as of now. Please order an anti-TPO Abs for her and ask her to do Free TFT every 3 months to check her thyroid status and dosage adjustment. Also hand over a Hospital Anxiety and Depression Scale (HADS), and ask her to fill it up, which will give you an idea about whether it is anxiety or depression. I use it quite frequently in my OPD. For her hyperthyroidism with depression you can put her on - 1) Tab. Carbimazole 20mg BD, and later can down titrate slowly upon next thyroid report, 2) Tab. Propranolol - LA 20mg BD is good enough, or if needed can go to 80mg/day or so, Please check exopthalmos status, is severe and having dry eye problem, you can prescribe her artifical tear drops like refresh tear 0.05%, and advise for taping the eye at night. Regarding depression, put her on Sertraline, start with 25mg OD for 6 days, and then escalate the dose to 50mg OD in morning for 6 months. If she needs etizolam 0.5mg at night, you can prescribe her a combination of etizolam 0.5mg plus propranolol 20mg at bedtime, instead of plain propranolol as advised above. I hope this will help you out to deal with this case. Another expert opinion on depression with hyperthyroidism can be given by respected sir @Gunjesh Kumar . Would love to hear from you sir.

Thank you so much sir
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Congratulations! Your case has been selected as Case of the day and you have been awarded 5 points for sharing the case. Keep posting your interesting cases, Happy Curofying!

Thank you doctor
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? HYPOTHYROIDISM.. NEED'S.. FURTHER EVALUATION WITH.. ENDOCRINOLOGIST OPINION

@Dr. Sepuri Krishna Mohan @Dr. Sepuri Tirumala Devi @Dr. Ajeet Singh kindly give ur valuable opinion

Treatment is ok

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