NR 511 Week 6 Case Study Part 2 PDF

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Week 6 Case Study Part 2...

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Week 6 Case Study Part 2

1. Primary Diagnosis: Hypothyroidism a. The hypothalamus secretes a hormone called thyrotropin releasing hormone (TRH). TRH is responsible for stimulating the pituitary gland causing it to produce thyroid stimulating hormone (TSH). From there, the TSH stimulates the thyroid gland to make and secrete T4. T3 is then produced during the conversion of T4 to T3. The T3 and T4 levels force a negative feedback on the creation of TRH and TSH. Hypothyroidism is a result of a change in structure and function of the involved organs and/or pathways (Patil, 2019). b. When reviewing that patient laboratory work, her TSH level is elevated and her free T4 levels are low. This indicates primary hypothyroidism (Koulouri & Gurnell, 2013). c. During the physical exam and gathering the HPI, the patient presents with positive weight gain, dry brittle hair, small but firm thyroid, feeling fatigued, not having the energy she normally would, having cold intolerance, constipation, dry skin, cramping in BLE. d. Her hemoglobin and hematocrit are WNL. Her RBCs are also WNL. This alone helps rule out anemia as a diagnosis. e. The patient did fill out the Patient Health Questionnair-9 (PHQ-9) form and she score a 10. Previously, she scored a 5 which shows a worsening in her depression or that her current medication needs increased or changed to something that could better help. This can also be contributing to her fatigue (Maletic, et al, 2017). 2. ICD 10 Code for Hypothyroidism is E03.9. 3. Treatment Plan: a. Medication i. The main treatment for hypothyroidism is Levothyroxine. When figuring a dosage for a patient, the dose is 1.6 mcg/kg per day. Levothyroxine should be taken on an empty stomach, usually 60 minutes prior to a meal or 3 hours after a meal. It is important to stay consistent when taking Levothyroxine in order to reach a therapeutic level (Patil, 2019). 1. Synthroid 131mcg, Dispense #30 Sig. 1 tab daily Refill: 0 ii. She is currently taking Prozac 20mg for her MDD. Seeing as how her depression seems to be worsening, I would increase her

Prozac. According to Epocrates she can take this in the morning and night (Epocrates, 2017). 1. Prozac 20 mg, Dispense #120, Sig 1 tab BID, Refill 1 b. Additional Testing: i. There will not be additional testing done for today. However, we need to assess the dosage of Levothyroxine to determine if it is an appropriate dose. Prior to the patient coming back for a follow up visit, she will need to have another thyroid panel completed. ii. Also, when the patient comes back for her follow up visit, she will fill out another PHQ-9 form to assess the increase in her medication. c. Patient Education: i. Take Levothyroxine on an empty stomach. 1. 30 minutes prior to breakfast 2. 3 hours after a meal (Patil, 2019) ii. It can take 2 weeks prior to noticing any changes with fatigue and cramping when starting Levothyroxine. iii. If symptoms worsen, inform provider. iv. If thoughts of suicidal or homicidal ideations, seek help v. It can take up to 4 weeks before you notice a change in mood with Prozac increase (Epocrates, 2017). vi. Do not stop taking Prozac abruptly (Eprocrates, 2017). d. Referrals i. No referrals are needed at this time. 1. A referral is not recommended for primary hypothyroidism. However, would is recommended if the patient is diagnosed with secondary hypothyroidism in order to withgo further evaluation (Curl, 2014). 4. Problem List: a. Hypothyroidism b. Obesity c. Fatigue d. Unexplained Weight Gain e. Depression f. HTN g. Postmenopausal h. Constipation i. Cold Intolerance

j. Muscle Cramps in BLE 5. Changes to Patient’s Treatment Plan: a. Based on the information provided by the patient and the symptoms presented in the physical examination, there are no changes I would make in the treatment plan. However, there is an elevation in the patient diastolic blood pressure. This can be due her untreated hypothyroidism (Polat, et al, 2017). During the patient’s next visit her blood pressure will be taken and changed will be made based upon the blood pressure at that time. If her diastolic blood pressure is decrease, then we will know it was due to her hypothyroidism. 6. Follow up: a. A follow up appointment should be made for 4 weeks after initial visit to ensure the condition has improved. b. A thyroid panel will need to be completed prior to follow up appointment to ensure the effectiveness of current treatment plan. c. If symptoms become worse prior to scheduled appointment, then the patient should come in sooner.

Reference Epocrates. (2017, March 7). Prozac. Retrieved December 3, 2019, from https://online.epocrates.com/drugs/115408/Prozac/Patient-Education. Gregory Curl, K. (2014). Hypothyroidism. (Cover story). Clinician Reviews, 24(7), 40– 46. Retrieved from https://search.ebscohost.com/login.aspx? direct=true&db=a9h&AN=97280162&sit e=eds-live&scope=site Koulouri, O., & Gurnell, M. (2013). How to interpret thyroid function tests. Clinical medicine (London, England), 13(3), 282–286. doi:10.7861/clinmedicine.13-3-282 Maletic, V., Eramo, A., Gwin, K., Offord, S., & Duffy, R. (2017, March 1). The Role of Norepinephrine and Its α-Adrenergic Receptors in the Pathophysiology and Treatment of Major Depressive Disorder and Schizophrenia: A Systematic Review. Retrieved December 1, 2019, from https://www.frontiersin.org/articles/10.3389/fpsyt.2017.00042/full. Patil, N. (2019, September 2). Hypothyroidism. Retrieved November 30, 2019, from https://www.ncbi.nlm.nih.gov/books/NBK519536/.

Polat Canbolat, I., Belen, E., Bayyigit, A., Helvaci, A., & Kilickesmez, K. (2017). Evaluation of Daily Blood Pressure Alteration in Subclinical Hypothyroidism. Acta Cardiologica Sinica, 33(5), 489–494. doi:10.6515/acs20170220b...