Download NR511 Week 6 Case Study and more Exams Nursing in PDF only on Docsity!
Greetings Professor and class,
NR511 Week 6 Case Study
CC: “Fatigue”
HPI :
A 56-year-old Caucasian female presents to the office today with complaints of generalized fatigue for the last 2-3 months and worsens on exertion, thus causing progressive worsening since onset. She reports feeling tired all of the time, sleep 8hrs per night, but does not feel well- rested. She stated that she has no energy to do the things she usually does and reported missing “1 day of work 2 weeks ago” because she could not get out of bed. She denies pain and reported no treatments or relieving factors.
ROS:
Constitutional: Denies fever, chills, or recent illnesses. She reported a 5lb weight gain since her last office visit 6 months ago.
HEENT: HEENT: Negative. No visual changes or diplopia. Denies any ear pain, coryza, rhinorrhea, or ST. She reported having a tonsillectomy as a child. Denies snoring or a history of sleep apnea. Denies any lymph node tenderness or swelling.
Respiratory : Denies cough, SOB, DOE or wheezing
CV : Denies chest pain
GI : Denies N/V/D. + Constipation
GU: Denies polyuria, polydipsia. + cold intolerance. Menopause status x 5 yrs.
Skin: Negative. No changes in skin, hair, or nails
Psych: Reports worsening of depressive symptoms but thinks it might be contributed to being “unproductive” and tired all of the time. Negative for SI/HI. No changes in sleep pattern, gets 8- 9hrs of sleep per night but not feeling rested.
Musculoskeletal: Reports generalized weakness and intermittent muscles cramping in calves
Allergies: Iodine dyes
Medications hx: Multivitamin, B-Complex, Prozac 20mg, Bisoprolol-HCTZ 2.5mg/6.25mg, Calcium 500mg & Vit D3 400IU.
Medical history: HTN, Depression, Postmenopausal status
PSH: Tonsillectomy
DDx:
Hypothyroidism : In hypothyroidism, the thyroid gland (TH) does not produce enough thyroid hormome. TH is “regulated by TRH through a negative-feedback loop that involves the anterior pituitary and hypothalamus” (McCance, Huether, Brashers, & Rote, 2019). Disruption of the TH will affect bodily functions such as how the body regulates temperature, heart rate, and all aspects of metabolism (McCance, Huether, Brashers, & Rote, 2019). The patient will report cold intolerance, constipation, weight gain, hoarseness, enlarged thyroid, decrease pulse rate, coarse dry hair, symptoms of depression, and fatigue (Dains, Baumann, & Scheibel, 2020, p.15).
Pertinent positive findings: constipation, weight gain, dry skin, cold intolerance, impaired
memory, worsening depression, and fatigue
Pertinent negative findings : enlarged thyroid, hoarseness, stiffness, muscle weakness and pain, tenderness, thinning hair, or bradycardia
Type 2 DM : The pathophysiology of diabetes mellitus is frequently characterized by peripheral insulin resistance, impaired regulation of hepatic glucose production, and the decline of beta-cell function, thus leading to a beta-cell failure (McCance, Huether, Brashers, & Rote, 2019, p.
2169). To simply explain, type II DM is related to the levels of insulin in the body, and the body’s ability to utilize it. Usually, obesity is common in the abdominal region, generally occurs in those older than 40 years with a strong genetic predisposition, and often associated with hypertension and dyslipidemia (McCance, Huether, Brashers, & Rote, 2019, p. 2169). Symptoms associated with type II DM are polydipsia, polyuria, polyphagia, fatigue, neuropathy, weight loss or weight gain, irritability, skin infections, nausea, acanthosis nigricans, breath that smells fruity or sweet, and blurred vision (American Diabetes Association, 2020).
Pertinent positive findings : fatigue, weight gain
Pertinent negative findings : polydipsia, polyuria, polyphagia, neuropathy, blurred vision, nausea, acanthosis nigricans, fruity and sweet-smelling breath, and irritability.
Chronic fatigue syndrome: is a disease marred by pain, fatigue, sleep defects, and other symptoms that are made worse by exertion and usually last longer than six months. It can also be characterized as flu-like symptoms that persist or recur with feelings of unrefreshing sleep, weakness, sore throat, muscle, and joint pain, problems with concentration, and new onset of headaches (Dains, Baumann, & Scheibel, 2020, p. 221). The patient’s physical exam may be normal with findings of tender cervical and axillary lymphadenopathy (Dains, Baumann, & Scheibel, 2020, p. 222). According to the Office of Women’s Health (2019), the symptoms of chronic fatigue syndrome can also be episodic.
Pertinent positive findings : fatigue, weakness, unrefreshing sleep, weakness, worsening of symptoms on exertion
Pertinent negative findings : headaches, muscle and joint pain, problems with concentration, sore throat
(McCance, Huether, Brashers, & Rote, 2019, p. 4684). To determine if hypothyroidism is the cause of the patient’s symptoms, obtaining labs for the thyroid-stimulating hormone (TSH, T and T4 levels may be necessary where in this diagnosis T3 & 4 is low with TSH elevated (Dains, Baumann, & Scheibel, 2020, p. 221). For diagnosis of type II diabetes mellitus, a urinalysis can screen for glycosuria, and then followed up with a fasting glucose level and laboratory testing for the patient’s hemoglobin A1c (Dains, Baumann, & Scheibel, 2020, p. 472). Lastly, Dains, Baumann, & Scheibel (2020, p. 222) recommends a CBC and ESR laboratory test to rule out the possibility of any acute infection for patients diagnosed with “Chronic Fatigue Syndrome.”
Reference(s)
Dains, J. E., Baumann, L. C., & Scheibel, P. (2020). Advanced health assessment and clinical diagnosis in primary care. 6th^ ed. St Louis, Missouri: Elsevier.
Diabetes Symptoms. (2020). American Diabetes Association. Retrieved from http://www.diabetes.org/diabetes-basics/symptoms/
McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2019). Pathophysiology: The biologic basis for disease in adults and children (8th ed.). St. Louis, MO: Mosby_._
Office of Women’s Health (2019). Chronic Fatigue Syndrome. Retrieved from https://www.womenshealth.gov/a-z-topics/chronic-fatigue-syndrome
Armitage, H. (2019). Biomarker for chronic fatigue syndrome identified. Standford medicine. Retrieved: June 10, 2019. From: https://med.stanford.edu/news/all- news/2019/04/biomarker-for-chronic-fatigue-syndrome-identified.htm
Abid, A., Ahmad, S., & Waheed, A. (2016). Screening for Type II Diabetes Mellitus in the United States: The Present and the Future. Clinical medicine insights. Endocrinology and
diabetes , 9 , 19–22. doi:10.4137/CMED.S
Symptoms & Causes of Diabetes. What are the symptoms of diabetes? National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved: June 10, 2019. From: https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms- causes
American Diabetes Association Diabetes Care. (2019). 42(Supplement 1); S13-S28. https://doi./10.2337/dc19-S
Blood test may detect myalgic encephalomyelitis / chronic fatigue syndrome. (2019). National Institutes of Health. Retrieved: June 14, 2019. From: https://www.nih.gov/news- events/nih-research-matters/blood-test-may-detect-myalgic-encephalomyelitis/chronic- fatigue-syndrome
Hello Chibuzor,
When I researched fatigue for a differential diagnosis DM was noted as a differential diagnosis. I selected DM type 2 because of her family history. Both grandparents and the patient’s parent all had Type 2 diabetes mellitus. You made a few great point in your response to my initial post where you pointed out the patient’s family history as well, but you also mentioned the patient’s physical inactivity and weight gain. You further discussed pertinent information in reference to stabilizing the patient’s thyroid dysfunction which would also improve her LDL level, hypertension, and heart rate.
Authors Javed & Sathyapalan (2016) stated In a systemic review, “6 out of 13 studies with patients with a mean TSH 4.8–9.8 mIU/l showed levothyroxine treatment resulted in an improvement in associated high total and LDL cholesterol. The author went on to state that treatment of subclinical hypothyroidism showed significant improvement in cardiovascular risk factors, cardiovascular risk markers, ncluding LDL cholesterol (Javed & Sathyapalan, 2016)”.
Thank you Chizbuzor for the important information you added to this discussion.
Javed, Z., & Sathyapalan, T. (2016). Levothyroxine treatment of mild subclinical hypothyroidism: a review of potential risks and benefits. Therapeutic advances in endocrinology and metabolism , 7 (1), 12–23. doi:10.1177/
hypothyroidism (Dunn & Turner 2016). The patient’s TSH level is noted at 6.770 uIU/mL and FT4 level is 0.62 ng/dL which is indicative of hypothyroidism.
- Pertinent positive findings: constipation, weight gain, dry skin, cold intolerance, muscle weakness, impaired memory, worsening depression, and fatigue
- Pertinent negative findings: puffy face, enlarged thyroid, hoarseness, muscle aches, stiffness, pain, irregular menstrual periods, tenderness, thinning hair, or bradycardia
The thyroid gland is a pertinent in manufacturing the thyroid hormones triiodothyronine which is T3 and thyroxine which is T4 and is needed in maintaining the body’s metabolism, growth, develop and energy (Mullur, Liu, & Brent, 2014).
Identify the corresponding ICD-10 code.
Hypothyroidism E03.
Provide a treatment plan for this patient’s primary diagnosis which
includes: Medication
The treatment and management of hypothyroidism includes prescribing levothyroxine (Synthroid) daily. Levothyroxine aids in the management and decreasing or “reversing the signs and symptoms” associated with hypothyroidism. Levothyroxine is an artificial material that mimics the T4 hormone. As stated by Jonklaas et al, 2014, “Levothyroxine (LT 4 ) has been considered the standard of care for treatment of hypothyroidism for many years. This treatment is efficacious when administered orally, has a long serum half-life that permits daily administration, and results in resolution of the signs and symptoms of hypothyroidism in the majority of patients (Jonklaas, 2014)”. Treatment with levothyroxine is life-long. Initial dosages for treatment of hypothyroidism is based off of the patient’s other medical conditions, age, and weight.
Initial doses for primary hypothyroidism is levothyroxine: 1.6 mcg / kg orally once daily and adjustments or an increase in dosages of 12.5 to 25 mcg every 4 to 6 weeks until the patients TSH becomes normal. The patient’s current weight is 81kg x 1.6 mcg= mcg of po levothyroxine daily. Dosing for this patient would be 125mcg (.0125mg) would be the daily recommended dose for this patient (Kalra et al, 2017).
The prescription would be written as:
Levothyroxine (Synthroid) 125mcg tablet for hypothyroidism
Disp: 60 tablets Refills: 0
Sig: Take 1 tablet by mouth daily.
Take on an empty stomach at least 30 to 60 minutes before breakfast
Take medication as order or directed. Keep taking this medicine (levothyroxine tablets) as you have been told by your doctor or other health care provider, even if you feel well.
Depression
Postmenopausal
Are there any changed that you would also make to the patient’s
overall treatment plan at this time? Must provide and EBM argument
for each treatment or testing decision.
No. No change in treatment would be made at this time due to the patient’s positive laboratory results that confirm a positive diagnosis of hypothyroidism. Fatourechi stated in 2019, that “The best laboratory assessment of thyroid function, and the preferred test for diagnosing primary hypothyroidism, is a serum TSH test (Fatourechi & Fatourechi, 2014)
Provide an appropriate follow-up plan;
Supportive care to decrease the patient’s anxiety is a main goal. Medication management is necessary in providing the appropriate care. Patient should return to the clinic for laboratory testing between 6-8 months to test for the patient’s T4 level (Hossain, Banerjee, Mondal, &Maiti, 2018). Patient’s should be examined for changes or increase in their laboratory findings to avoid thyrotoxicotic values.
Dunn, D. & Turner, C. (2016). Hypothyroidism in women. Nursing for women’s health. Volume 20, Issue 1, p93-98. Doi: https://doi.org/10.1016/j.nwh.2015.12.
Fatourechi, M. M., & Fatourechi, V. (2014). An update on subclinical hypothyroidism and subclinical hyperthyroidism. Expert Review of Endocrinology & Metabolism, 9(2), 137-
- doi:10.1586/17446651.2014.
Hossain, S.,Banerjee,M., Mondal, S., & Maiti, A. (2018). A comparative study on effect of the evening versus morning intake of levothyroxine in patients of hypothyroidism. Thyroid Research & Practice , 15(2), 89-93. Doi:10.4103/trp.trp_11_
McAninch, E. A., & Bianco, A. C. (2016). The History and Future of Treatment of Hypothyroidism. Annals of internal medicine , 164 (1), 50–56. doi:10.7326/M15-
Mullur, R., Liu, Y. Y., & Brent, G. A. (2014). Thyroid hormone regulation of metabolism. Physiological reviews , 94 (2), 355–382. doi:10.1152/physrev.00030.
Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S. (2014). American Thyroid Association Task Force on Thyroid Hormone Replacement. Guidelines for the treatment of hypothyroidism: prepared by the american thyroid association task force on thyroid hormone replacement. Thyroid : official journal of the American Thyroid Association , 24 (12), 1670–1751. doi:10.1089/thy.2014.
Symptoms & Causes of Diabetes. Thyroid tests National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved: June 13, 2019. From: https://www.niddk.nih.gov/health-information/diabetes/overview/symptoms-causes
Kalra, S., Agarwal, N., Aggarwal, R., Agarwal, S., Bajaj, S., Bantwal, G., … Unnikrishnan, A. G. (2017). Patient-centered Management of Hypothyroidism. Indian
- Ideal body weight (IBD) men = 50 kg + 2.3 kg x (height in inches – 60)
- Ideal body weight (IBW) women = 45.5 kg + 2.3 x (height in inches – 60)
The patient is 5’7”. 45.5 kg + 2.3 kg = 47.8 kg x (67 inches – 60) = 139.6 lbs \ 2.2 kg =63.45 kg
For this patient the IBW would be 63.45 kg. Prescribing Levothyroxine (Synthroid) for the patient based off of the IBW would mean the dosage would be 100 mcg once daily in the am 30 to 60 minutes before eating. When researching proper dosing for Levothyroxine (Synthroid), I read for prescribing for individuals over 50 years of age / or individuals with Cardiovascular Disease, the initial dose should start at 12.5 to 25 mcg orally once per day. Also, dosing should be adjusted between 6 to 8 weeks intervals until TSH returns to normal and the thyroid begins to function properly. Javed (2016) stated, “Levothyroxine treatment is generally recommended appropriate when the TSH level is >10.0 mIU/l (Javed, 2016)”.
The prescription would read:
Levothyroxine (Synthroid) 25mcg tablet for hypothyroidism
Disp: 60 tablets Refills: 0
Sig: Take 1 tablet by mouth daily.
Take on an empty stomach at least 30 to 60 minutes before breakfast
Take medication as order or directed. Keep taking this medicine (levothyroxine tablets) as you have been told by your doctor or other health care provider, even if you feel well. Have your blood sugar checked as directed by the doctor. Have your blood work check as you have been directed by the doctor. Take the missed dose as soon as remember. If the missed dose is too close to your normal dose, skip it and resume your normal schedule. Some foods may interrupt the absorption of this medication. It may take 4- weeks before you see improvement in symptoms
I would like to follow up with the patient within 3-6 months preferably at the 3rd^ month to re- evaluate the patient and to repeat lab work to check her TSH level. I would feel most comfortable with having the patient to return in 3 months because I would want to know if the patient’s symptoms have improved, gotten worse, or unchanged. Monitoring the patient closely will allow both the patient and I to implement a different care plan if need be.
Javed, Z., & Sathyapalan, T. (2016). Levothyroxine treatment of mild subclinical hypothyroidism: a review of potential risks and benefits. Therapeutic advances in endocrinology and metabolism , 7 (1), 12–23. doi:10.1177/
Kenneth,
Your post and thoughts were well organized. I like to point out that in your post you opted to treat the patient’s depression. I on the other hand did not. It shows that you are being proactive in managing the all of the patient’s symptoms. I on the other hand decided not to treat the patient for depression based off of her score because I thought that if I begin the patient on the
