NR 511 week 6 discussion part 2 PDF

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NR 511 Week 6 Discussion part 2...

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Now, assume that any procedures and/or testing which were performed are NORMAL. 1. What is your primary (one) diagnosis for this patient at this time? (support the decision for your diagnosis with pertinent positives and negatives from the case) Diagnosis: Hypothyroidism Rationale: Patient labs show TSH elevation of 6.770 and decreased T4 of 0.62. These levels indicate that the thyroid gland is not releasing adequate amounts of hormones which are thereby causing the anterior pituitary gland to increase the release of TSH in effort to cause the gland to increase release of T4. These labs are indicative of hypothyroidism (Eligar, Taylor, Okosieme, Leese, & Dayan, 2016). Although vitamin D levels are not given, it cannot be ruled out as a contributory condition. Depression screening warrants attention but is likely scored based upon the patient’s feelings due to her hypothyroid state. Pertinent Pos/Neg: As stated in the previous study, pertinent positives for hypothyroidism include female, fatigue, cold intolerance, decrease LE DTRs, dry skin, coarse hair, weight gain, muscle cramping, and constipation. Pertinent negatives include lack of goiter, no family history, normal LOC, lack of hair loss, lack of bradycardia (Bhargava, 2016). 2. Identify the corresponding ICD-10 code. E03.9 Hypothyroidism, unspecified 3. Provide a treatment plan for this patient's primary diagnosis which includes: 

Medication At this time, I would prescribe the following medication: Levothyroxine (Synthroid) 25 mcg Disp: #30 Sig: Take one tablet by mouth every morning RF: 3 (Jonklaas, Bianco, Bauer, Burman, Cappola, Celi, Sawka, 2014). The goal of treatment for hypothyroidism is aimed at resolving symptoms, bringing thyroid hormone levels to normal, and avoiding toxicity or under treating the condition (Jonklass et al., 2014). The primary

treatment for hypothyroidism is daily administration of thyroid hormone to restore the patient to a euthyroid state. In order to achieve this state, a synthetic preparation of T4 called levothyroxine is generally administered. The recommendation for patients older than 50 years of age should be treated with a start dose of 25 to 50 mcg per day (Jonklass et al., 2014). .

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Any additional testing necessary for this particular diagnosis* After levothyroxine initiation, it is recommended that the TSH and FT4 be re-evaluated every 4-8 weeks while the dosage is being adjusted until they are within normal range (Jonklaas et al., 2014). Since I will be starting the dosage at a low level, I will order a TSH and FT4 to be drawn in one month. In addition to those labs, I will order a fasting lipid panel that can be drawn at the same time. This is due to the fact that those with hypothyroidism are at increased risk for atherosclerotic heart disease. Therefore, a baseline measurement should be obtained so that treatment can be promptly initiated, if needed (Jonklaas et al., 2014). I would also like to test antithyroid antibody titers via antimicrosomial antibody to help narrow the cause for development of this condition. If antibodies are present, this will determine that autoimmune disease, such as Hashimoto’s thyroiditis, is the likely cause or if it could be due to disease of the hypothalamus or pituitary (Eligar, et al., 2016). Patient education When prescribe a patient with levothyroxine, it is important to educate the patient to take levothyroxine

on an empty stomach to ensure proper absorption, and preferably early in the morning everyday same time (Epocrates, 2019). I would instruct patient not to take levothyroxine within 4 hours of calcium carbonate, ferrous sulfate, Carafate, PPIs, multivitamin, or Cholestyramine because it can decrease the effect of it. I would instruct patient to avoid grapefruit juice as this will decrease absorption of medication (Epocrates, 2019). I would remind patient that this medication should be taking every day for the rest of her life. After initiation of therapy, I would educate the patient that symptom improvement can be expected two weeks after and the resolution of symptoms could take about three to six months (Jonklaas et al., 2014). I would also educate the patient to seek emergency treatment if they experience any signs of thyrotoxicity, such as tremors, change in

consciousness, fast heartbeat or palpitations, nervousness, or chest pain (Epocrates, 2019). Most importantly, the patient must be educated on the importance of follow-up visits and understand that lifelong therapy and compliance with medication, as well as ongoing monitoring, is needed to properly manage this diagnosis (Jonklaas et al., 2014)

Referral

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I would refer any patient newly diagnosed with hypothyroidism or hyperthyroidism to an endocrinologist for further evaluation. With the patient’s family history of cardiovascular disease and current HTN, referral to cardiology for cardiac clearance can also be justified.

4. Provide an active problem list for this patient based on the information given in the case. Generalized fatigue with exertional exacerbation Muscle cramps Hypothyroid state Constipation Decreased DTR (LE) ETOH use Weight gain History of Depression with recent PHQ-9 increase Family history of cardiovascular disease, T2DM, HTN, Hyperlipidemia HTN 5. Are there any changes that you would also make to this patient’s overall treatment plan at this time? Must provide an EBM argument for each treatment or testing decision. Primary hypothyroidism has shown to increase the risk for ischemic heart disease, MI, and cardiac mortality Ning, Cheng, Liu, Sara, Cao, Zheng, Wei (2017). Therefore, I would also increase the dose of her current antihypertensive medication. I would prescribe the following medication:

Bisoprolol-HCTZ (Ziac) 5mg/6.25mg Disp: #30 Sig: Take one tablet by mouth daily RF: 3 (Hollier, 2016)

If her current elevation in blood pressure is due to this secondary cause, the administration of levothyroxine may help to reduce her blood pressure. However, I think it is important to treat the elevated blood pressure at this time. At the next office visit, I would reduce the antihypertensive dose if her blood pressure improves with levothyroxine. Although the PHQ-9 screening completed on this patient indicated moderate severity depression (score of 10) in comparison to mild severity during the previous visit (score of 5), I am not inclined to make any adjustments to her Prozac dosage at this time. According to Berent, Zboralski, Orzechowska, & Galecki (2014), the addition of levothyroxine to a medication regimen containing an SSRI can both accelerate and enhance the SSRIs antidepressant effects. Therefore, I will plan to reassess the PHQ-9 on the next followup visit. 6. Provide an appropriate F/U plan. Follow up in six weeks for recheck of TSH and T4 levels; will adjust dosage at this time. Continue monitoring weight, HTN, and depression as this is likely due to hypothyroid state and should improve with normalization of thyroid levels (Jonklaas et al., 2014).

References Berent, D., Zboralski, K., Orzechowska, A., Galecki, P. (2014). Thyroid hormones association with depression severity and clinical outcome in patients with major depressive disorder. Molecular Biology Reports, 41(4), 2419-2495. Bhargava, A. (2016). Hypothyroidism: To screen or not to screen, that is the question? Journal of Thyroid Disorders & Therapy, 5(2). doi:10.4172/2167-7948.1000e126 Eligar, V., Taylor, P., Okosieme, O., Leese, G., & Dayan, C. (2016). Thyroxine replacement: A clinical endocrinologist’s viewpoint. Annals of Clinical Biochemistry, 53(4), 421-433. doi: 10.1177/0004563216642255 Epocrates. (2019). Primary hypothyroidism. Retrieved from https://online.epocrates.com/diseases/53534/Primary-hypothyroidism/Diagnostic-Tests Hollier, A. (2016). Clinical guidelines in primary care (2nd ed.). Scott, LA: Advanced Practice Education Associates. Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., Sawka, A. M. (2014). Guidelines for the treatment of hypothyroidism: Prepared by the American thyroid association task

force on thyroid hormone replacement. Thyroid, 24(12), 1670–1751. http://doi.org/10.1089/thy.2014.0028 Ning, Y., Cheng, Y. J., Liu, L. J., Sara, J. D. S., Cao, Z. Y., Zheng, W. P., Wei, Y. X. (2017). What is the association of hypothyroidism with risks of cardiovascular events and mortality? A meta-analysis of 55 cohort studies involving 1,898,314 participants. BMC Medicine, 15, 21. http://doi.org/10.1186/s12916017-0777-9...