NR 603 Week 5 case study PDF

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The topic was assigned based on your lowest area on the APEA midterm exam. This is a WH topic for Perimenopause/Menopause...

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Perimenopause Demographics: AW, a 55 yr. African-American female, Height: 5’6 Weight: 210, BMI: 33.9 Vitals: 140/88, 77, 16, 97.8, 99% on room air NKA/NKDA PMH: HTN, Depression, Hypothyroidism, Hypercholesterolemia, Full-term SVD x2 both pregnancies GDM; diet control only, no meds or birth complications. Breastfed both children for 6 months. PSH: Partial thyroidectomy at the age of 21 Current Medications: Sertraline, Metoprolol, Atorvastatin, Synthroid, Prilosec, and an OTC sleep aid. SH: Married for 15 yrs., No recreational drugs, alcohol, or smoking. A college graduate, works PT at her family’s business, spouse works FT and attends school PT. HPI: Upon entering room, patient is AAO, appropriately greeting me as I enter. She’s wellgroomed and kempt. No outwardly distress noted. When asked, pt. states she’s presenting for ongoing tiredness and moodiness, which she says her family complains more of that she’s actually noticed herself. She says she’s always felt sluggish, but lately she’s been feeling so down that she mentally doesn’t want to do anything. She states she’s been taking all of her prescribed medications; she still has her Mirena IUD which she’s happy with due to no menstrual cycles or breakthrough bleeding. Since her last visit, I noticed that the pt. has lost around 20 pounds and when asked to discuss further, she says that it’s intentional weight loss to get her health in better order, however she says she hasn’t started working out because she just can’t muster up the energy to do anything outside of what she’s already doing with PT work and family life. She also reports not sleeping well and frequently wakes up feeling really tired. She states her husband reports snoring; however, she says, she thinks that’s because she’s so exhausted that when she finally does get to bed, she just crashes. Main Diagnosis: Perimenopause/Menopause. 3 Differential Diagnosis: 1. Metabolic Syndrome 2. Pituitary Tumor 3. Obstructive Sleep Apnea In general, menopausal women, have increased SBP that is often associated with lower levels of estrogen from hormonal changes during menopause. At times, African American women are more susceptible to mental health illness due to their social roles and positions, such as in being heads of the household, taking care of children, or caring for aging family members. (Still, Tahir, Hassan & Gary, 2020). When our body’s BMI is above the recommended measurements, our body’s sympathetic nervous system (SNS) becomes overstimulated, which directly correlates with a rise in weight, blood pressure, cholesterol and glycemic levels (Smojlo et al., 2020). Metabolic syndrome is influenced by not only a rise in our SNS system, but also the pathologic regulation of TSH, prolactin, cortisol, and fT4, all of which can affect the adrenal, thyroid, and pancreatic glands. A.W. may have a busy home life like most Americans today and living in a pandemic she’s probably experiencing large amounts of stress, which is can cause an elevation in both her prolactin and cortisol levels. Furthermore, when thyroid levels are abnormal, this can lead to an elevation in both prolactin and lipid levels. Gestational diabetes increases a woman’s future risk of developing Type 2 Diabetes Mellitus up to 60% within two decades of delivering her children. Many symptoms of Type 2 DM go unnoticed, placing patients at a higher risk for complications, resulting in cardiovascular disease

such as MI, HTN, PAD, or CHF. Likewise, a patient like A.W. who currently has CVD in the form of HTN and hyperlipidemia, further places her at a higher risk in developing Type 2 DM (Glovaci, Fan & Wong, 2019). Obstructive sleep apnea is characterized by recurrent episodes of upper airway obstruction, leading to fragmented sleep and episodes of hypoxia during sleep. Snoring by itself, is independently associated with a higher fat mass in menopausal women; therefore, a woman’s body composition is important in preventing OSA. Moreover, regular snoring, greater than 3 nights a week, has a strong association with obesity, hypertension and diabetes mellitus, in addition to downward shifts in both estrogen and progesterone levels during menopause; allowing for a continuum of airway resistance or snoring (Zhou et al., 2020). Another common concern with perimenopausal and menopausal women is an increase in prolactin levels. Most providers think of prolactin concerns when a woman has just given birth, when in fact, a woman like A.W., may have an abnormal prolactin level due to her obesity, lipid disorder, life stressors, or abnormal thyroid levels (Pekic, Stojanoskac & Popovica, 2019). Pituitary tumors are for the most part benign and asymptomatic in nature, however, during the period of perimenopause and menopausal hormonal fluctuations, the pituitary gland can go through hypersecretory phases, allowing for small tumors or adenomas to arise from their respective site (Melmed & Jameson, 2018). Furthermore, central obesity, psychiatric changes such as A.W.’s moodiness, HTN, possible diabetes, and thyroid disease, all of which gives suspicion of a hormonal pituitary tumor. Relevant testing: Stressful life events will be measured using the 43-point Life Stress Questionnaire or LSQ. These life events are measured by numerical value, describing the magnitude of the of that stressful life event and or illness over the last two years. Life events such as financial concerns, death of a spouse, or personal illness, are all rated numerically. Once calculated, if totaled score responses are > 300, this places A.W. at risk for a stress-induced illness (Still, Tahir, Hassan & Gary, 2020). Serum Prolactin, LH, IGF insulin growth factor, and FSH level initially when a pituitary tumor is suspected. If levels are abnormal, we will proceed with an MRI to further assess pituitary size and rule out a pituitary adenoma (Pałubska, Adamiak-Godlewska, Winkler, Romanek-Piva, Rechberger & Gogacz, 2019). A Ferritin, iron, total iron binding capacity and transferrin are all iron studies used to detect anemias, however, her serum ferritn level will be the most test for iron deficiency anemia. level will be the most appropriate serum marker to assess for iron deficiency anemia as it will rise in during inflammatory processes CRP level: since obesity causes an increase in inflammation, by measuring a CRP level, any revelation of inflammation can lead to worsening vascular and myocardial injury (Glovaci, Fan, & Wong, 2019). A HA1c, TSH, fT4, lipid panel, and cortisol markers: will assist in establishing a true metabolic syndrome (Dutka, Chmyr, Svitlyk, & Leontieva, 2019). A snoring frequency assessment, with anthropometric measurements, such as her BMI, height, and weight all of which support both an OSA and metabolic syndrome determination (Zhou et al., 2020).

References:

Dutka R., Chmyr N., Svitlyk H., & Leontieva Z. (2019). Prolactin, cortisol, free thyroxine and thyroid-stimulating hormone: Markers of staging of metabolic syndrome as a risk factor of coronary artery disease and type 2 diabetes mellitus. Georgian Medical News, 297 (pp. 80-83). Glovaci, D., Fan, W., & Wong, N. (2019). Epidemiology of diabetes mellitus and cardiovascular disease. Current Cardiology Reports, 4 (21). doi: 10.1007/s11886-019-1107-y. PMID: 30828746. Melmed, S., & Jameson, J. (2018). Pituitary tumor syndromes. Jameson, J., Fauci, A., Kasper, D., Hauser, S., Longo, D. & Loscalzo, J. Harrison's Principles of Internal Medicine, 20e. McGraw-Hill. https://accessmedicine-mhmedicalcom.chamberlainuniversity.idm.oclc.org/content.aspx?bookid=2129§ionid=179924292 Pałubska, S., Adamiak-Godlewska, A., Winkler, I., Romanek-Piva, K., Rechberger, T., & Gogacz, M. (2017). Hyperprolactinemia: A problem in patients from the reproductive period to the menopause. Menopause Review, 16(1), 1-7. https://doi.org/10.5114/pm.2017.67364 Pekic, S. Stojanoska, M., & Popovic, V. (2019). Hyperprolactinemia/prolactinomas in the postmenopausal period: Challenges in diagnosis and management. Neuroendocrinology, 109 (1), 28-33. Smoljo, T., Stanić, I., Sila, S., Kovačić, U., Crnošija, L., Junaković, A., Adamec, I., Hojsak, I., Krbot, M., Skorić, K., & Habek, M. (2020). The relationship between autonomic regulation of cardiovascular function and body composition. Journal of Obesity and Metabolic Syndrome, 29(3): 188-197. doi: 10.7570/jomes20041 Still, C. Tahir, S., Yarandi, H., Hassan, M., & Gary, F. (2019). Association of psychosocial symptoms, blood pressure, and menopausal status in African American women. Western Journal of Nursing Research. 42(10):784-794. doi:10.1177/0193945919898477

Zhou, Y., Liu, F., Changbin, L. ZhenG, Y., Hu, J., Zhou, Y., Lulu, Z., Geng, L., Jiang, S., Teng, Y., & Tao, M. (2020). Association of snoring and body composition in (peri-post) menopausal women. BMC Women’s Health. doi: https://doi.org/10.1186/s12905-020-01025-2

Case Study Part 2: Due Thursday Treatment for Differential Diagnosis: Pituitary Tumor As i d ef r o mr a d i a t i o na n dt u mo r s u p p r e s s a n t t r e a t me n t s , o n eo f t h ewa y st h a t p r o v i d e r sd e c r e a s ee x c e s s i v ep r o l a c t i n l e v e l so r s h r i n kt u mo r si st oa d mi n i s t e r d o p a mi n er e c e p t o ra g o n i s t s .At t h er i g h t d o s a g e , d o p a mi n ea g o n i s t ss u c ha s Br o mo c r i p t i n e( 2 . 5 1 5mg / d a i l y )o rCa b e r g o l i n e( 0 . 2 5 1mgt wi c ewe e k l y ) wo r kb yi n h i b i t i n gt h es e c r e t i o no f a d r e n o c o r t i c o t r o p i ch o r mo n e( ACTH) , ah o r mo n ep r o d u c e di nt h ep i t u i t a r yg l a n di nt h eb r a i n .At t h er i g h t d o s a g e , d o p a mi n ea g o n i s t s , wi l l g r e a t l yr e d u c ea n dn o r ma l i z ep r o l a c t i nl e v e l sa n dr e d u c eap i t u i t a r yt u mo ru pt o7 0 % ( Sc h i mme r &F u n d e r , 2 0 1 7 ) . Bo t ha r eg r e a t o p t i o n s , h o we v e r , c a b e r g o l i n eh a ss h o wnt ob eab e t t e ro p t i o ni nt e r mso f s t 1 p a s se ff e c t i nt h el i v e ra n dh a sl o we ra d v e r s es i d ee ff e c t ss u c ha sn a u s e a , v o mi t i n g , c o n s t i p a t i o n , h e a d a c h e , d i z z i n e s s , a n do r t h o s t a t i ch y p o t e n s i o n . T woo f t h es i d ee ff e c t st h a t p r o v i d e r sa r eu s u a l l yc o n c e r n e da b o u t , i n c l u d e b o t hh y p o t e n s i o na n di t sl i n kt ov a l v u l a r h e a r t d i s e a s e , o f wh i c hi su s u a l l yd u ewh e na d mi n i s t e r e df o r l o n g t e r mu s e .

I nt e r mso f p a t i e n t c o mp l i a n c e , t h i sc a b e r g o l i n ec a nb eg i v e n1 2 xawe e kv e r s u sd a i l y , a l l o wi n ge a s i e r p a t i e n t a d mi n i s t r a t i o n .On c ep r o l a c t i nl e v e l sa r en o r ma l a n dt h e r e ’ sn oe v i d e n c eo f at u mo r , d o s a g e ss h o u l db et a p e r e d d o wna n dd i s c o n t i n u e d . Su r g e r ya n dr a d i a t i o na r eu s u a l l yr e s e r v e df o rp a t i e n t swh oc a n ’ t t o l e r a t ea n yf o r mo f me d i c a t i o n( Th a p a&Bh u s a l , 2 0 2 0 ) . Re f e r e n c e s : Sc h i mme r , B. &F u n d e r , W. ( 2 0 1 7 ) . Ad r e n o c o r t i c o t r o p i ch o r mo n e , a d r e n a l s t e r o i d s , a n dt h ea d r e n a l c o r t e x . Br u n t o n , L . , Hi l a l Da n d a n , R. , &Kn o l l ma n n , B. Go o d ma n&Gi l ma n ' s : Th ePh a r ma c o l o g i c a l Ba s i so f Th e r a p e u t i c s , 1 3 e . Mc Gr a wHi l l . Re t r i e v e df r o mh t t p s : / / a c c e s s me d i c i n e mh me d i c a l c o m. c h a mb e r l a i n u n i v e r s i t y . i d m. o c l c . o r g / c o n t e n t . a s p x ? b o o k i d =2 1 8 9 &s e c t i o n i d =1 7 2 4 8 2 6 0 5 T h a p a , S. &Bh u s a l , K. ( 2 0 2 0 ) .Hy p e r p r o l a c t i n e mi aI n : St a t Pe a r l s[ I n t e r n e t ] . T r e a s u r eI s l a n d : St a t Pe a r l s . Re t r i v e d f r o mh t t p s : / / www. n c b i . n l m. n i h . g o v / b o o k s / NBK5 3 7 3 3 1 /...