Hypothyroidism - Case study examples PDF

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You are working in a community outpatient clinic where you perform the intake assessment on R.M., a 38-year-old woman who is attending graduate school and is very sedentary. Her chief complaint is overwhelming fatigue that is not relieved by rest. She is so exhausted that she has difficulty walking to classes and trouble concentrating when studying. She reports a recent weight gain of 15 pounds over 2 months without clear changes in her dietary habits. Her face looks puffy, she has experienced excessive hair loss, and her skin is dry and pale. She complains of generalized body aches and pains with frequent muscle cramps and constipation. You notice she is dressed inappropriately warm for the weather. ■ Chart View: Vital Signs Blood pressure 142/84 mm Hg Heart rate 52 beats/min Respiratory rate 12 breaths/min Temperature 96.8 ° F (36 ° C) 1. Compare her VS with those of a healthy person at her same age. R.M vitals BP 142/84 (Normal 120/80) HR 52 (Normal 60-100) RR12 (Normal 10-20) Temp 96.8 (Normal 97-99) 2. List eight general questions you might ask R.M. to assist in determining what is going on with her. -When did you notice your symptoms started? -Does anyone in your family have thyroid issues? -Do you do any physical activity? -What does your physical activity look like? -What does your diet look like? -What does a typical day look like for you? -Do you take any medications? -Do you have any medical history I should be aware of? -Are you feeling okay, any symptoms of depression? 3. You know that potential causes for some of R.M.'s symptoms include depression, hypothyroidism, anemia, cardiac disease, fluid and electrolyte imbalance, and allergies. As part of your screening procedures, describe how you would begin to investigate which of these conditions probably do not account for R.M.'s symptoms. I would ask for labs (TSH CBC and a comprehensive metabolic panel EKG) 4. Unnecessary diagnostic tests are expensive. What tests do you think would be the most appropriate for R.M., and why?.

TSH and CBC I feel like this would show the most amount of likely info that would lead to the diagnosis or point us in the right way Laboratory Test Results: TSH 20.9 mU/L (2-10 mU/L) TRH 18.8 ng/dL (2-10 ng/dL) T 3 24 mU/L (70-205 ng/dL) Free T 4 0.2 ng/dL (0.8-2.4 ng/dL) ■ 5. Interpret R.M.'s laboratory results. R.M. has primary hypothyroidism. TSH 20.9 (high) normal range (2-10) TRH 18.8 (High) (2-10 ng/dL) T 3 24 mU/L(Low) (70-205 ng/dL) Free T 4 0.2 ng/dL(Low) (0.8-2.4 ng/dL) 6. The family practitioner affirms a diagnosis of hypothyroidism. With this diagnosis, what other signs and symptoms would you want to investigate? I would want to investigate the patient's frequent muscle cramps and constipation and investigate why she is dressed inappropriately warm for the weather. 7. The family practitioner prescribes levothyroxine (Synthroid) 1.7 mcg/kg body weight/day. At this time, R.M. weighs 130 pounds. What should be her daily dose of levothyroxine in milligrams? How would her prescription read? Calculate her daily dose. 0.1mg of levothyroxine (synthroid) 8. Why would you want to obtain a complete drug history on R.M.? A complete drug history is essential for any patient that is starting a new drug because not all drugs interact well with each other. I would also ask about any herbal remedies, vitamins, and over the counter medications. 9. What general teaching issues will you address with R.M. in regard to hypothyroidism? Hypothyroidism is low or no thyroid release to the thyroid gland. This may lead to weakness or tiredness, sluggishness, weight gain, cold intolerance, constipation, cool skin, slowing down of the CNS system 10. What teaching needs will you review with R.M. in regards to her medication? Take one pill everyday at the same time everyday. It should be 30 to 60 minutes before mealtime. If you missed a dose take it as soon as you remember unless it is close to the next dose time. 11. R.M. wonders whether she should take iodine supplements if she decreases her salt intake. She recognizes that salt is a significant source of iodine in her part of the country. What would you explain to her?

Living in the United states you normally do not need iodine supplements. The reason for this is due to the fact that iodine has been added to salt and is also added to other foods. 12. What should you teach R.M. regarding prevention of myxedema coma? Teach RM to take prescribed medication at the same time every day. Also teach her to avoid stressful situations such as infections, trauma, or exposure. Myxedema is an extreme complication of hypothyroidism exhibiting mental deterioration. 13. Before R.M. leaves the clinic, she asks how she will know whether the medication is “doing its job.” Outline simple expected outcomes for R.M. Some expected outcomes is R.M is gradually increasing her exercise and has higher tolerance over the next 2 months. The patient will normal bowel movement, maintain normal body temperature, and a decrease in weight. Will also note improved mental function, improved skin function, and a decrease in skin dryness. 14. Several weeks later, R.M. calls the clinic stating she can't remember whether she took her thyroid medication. What additional data should you obtain, and how would you advise her? Forgetting to take the medication can lead to several complications such as fatigue, depression, myxedema coma, low temperature. Suggest the patient in placing an alarm to not forget to take her medication at the same time everyday. CASE STUDY OUTCOME R.M. comes in 2 months later for a follow-up visit. You can't believe she is the same person. She looks and walks as if she were 10 years younger. Her skin appears more radiant, and her hair looks much healthier. “You can't believe how different I'm feeling,” she says. “I didn't know how bad off I was; I'm starting to live again.”...