NR511 Week 6 Case Study Part 2 Complete Solution
Primary Diagnosis:
The primary diagnosis for J.D. is hypothyroidism; this is based on the lab results
... [Show More] of a TSH level 6.77 and a FT4 level 0.62. According to Mechanik et al., (2017) hypothyroidism is diagnosed by an elevated TSH level and a low T4 level accompanied with the presence of clinical characteristics. The patient presented with pertinent positives of weight gain, worsening depression, cold intolerance, dry skin, coarse hair, generalized weakness, decreased DTR of LE bilat., and constipation. Although the patient had pertinent negatives for hypothyroidism, which included small, firm thyroid upon examination, normal heart rate, normal hair distribution, no ridging, pitting, or brittleness of the nails, no hoarseness, or pedal edema. The identification of an elevated TSH, low T4, and the pertinent positive findings are enough to conclude a diagnosis of hypothyroidism.
ICD-10 code: E03.9 hypothyroidism, unspecified. Until further evaluation of this patient is performed a cause of her new diagnosis if hypothyroidism cannot be determined.
Treatment plan:
1. Medication:
According to Chaker, Bianco, Jonklass & Peters (2017) a newly diagnosed patient with hypothyroidism should be started on thyroxine therapy. The starting dose Levothyroxine should be calculated at 1.6mcg/kg/day. J.D. is 180lbs; this would make her daily dose 130mcg/day. However, the manufactured dosages of Levothyroxine are 25, 50, 88, 100, 112, 125, 137, 150, 175, 200, and 300mcg tablets. (Epocrates, 2019). The dose should be started at 125mcg daily. This initial dose should be taken for 4 to 6 weeks and the pt. should return for follow up and repeat blood work to evaluate the dosage. The dosage may need to be adjusted every 4 to 6 weeks until the serum TSH levels return to a normal level and the patient is without symptoms. These adjustments should be made in increments of 12.5 to 25mcg (Mechanik et al., 2017).
Levothyroxine 125mcg
Sig: 1 tablet po qd on an empty stomach 30 minutes to 1 hour before breakfast
Disp: # 30 (thirty)
Refills: 1
2. Additional testing:
Hashimoto’s is an autoimmune disorder that attacks the thyroid leading to hypothyroidism. Further testing with an anti-TPO antibody test would identify if an autoimmune disease is the cause of the patient’s diagnosis of hypothyroidism. Women are more likely to develop Hashimoto’s than men. It is valuable to determine the cause of the abnormal thyroid hormone levels (Frohlich & Wahl, 2017).
3. Patient education:
• Plan of care and management
• Thyroid hormone therapy is lifelong medication management
• There may be a need to titrate the medication dosages and thyroid hormone levels will need to be performed regularly
• Symptomatic improvement can be seen in as little as 2 weeks of medication therapy, however, it may take 3 to 6 months to completely resolve
• Medication education; should be taken on an empty stomach first thing in the morning. Do not eat for 30 minutes to 1 hour after taking medication. Do not take with antacids due to decreased absorption
• High fiber diet can decrease symptoms of constipation
• Hyperlipidemia is common in patients with hypothyroidism and lipids levels will be monitored
• Depressive symptoms should improve as thyroid hormone levels return to a normal level
• Importance of reporting signs or symptoms of toxicity, infection, or cardiac symptoms (Hollier, 2018).
4. Referral:
At this time referral to an endocrinologist is not indicated. In the event that the proper dosage of Levothyroxine cannot be achieved or the TPO antibody test was positive a referral to endocrinology would be appropriate (Mechanik et al., 2017).
Active Problem List:
• Hypothyroidism
• Hypertension
• Depression
• Post menopausal
• Fatigue
• Overweight
• Constipation
• Muscle cramps
• Generalized weakness
• Dry skin
Changes to the overall plan of care?
I would proceed with the current plan to start the pt. on Levothyroxine 125mcg po qd. The medication requires a minimum of 2 weeks before the patient may notice relief of symptoms; her complaints of worsening depression would need to be monitored. This can be achieved by having the patient follow up in 2 weeks for a PHQ-9 screening. The PHQ-9 is a tool developed for the use in primary care to evaluate and identify symptoms related to depression; it is a self-report screening tool (Manea, Gilbody, & McMillian, 2015). The patient is without suicidal or homicidal ideations, however her PHQ 9 score did increase from a 5 to a 10 over the past 6 months. If her PHQ 9 score continued to rise her Prozac would need to be increased and further evaluation would be warranted. J.D. also had an elevated BP reading of 146/95 although she is taking Bisoprolol-HCTZ 2.5mg/6.25mg qd. I would like her to take her BP at home daily for 2 weeks and bring those readings in with her when she came in for her follow up. If her BP was still elevated an adjustment or addition to her blood pressure medication management would be necessary (Hollier, 2018).
Follow up:
The patient will follow up in 2 weeks for evaluation of worsening symptoms of depression, as well as a blood pressure check (Hollier, 2018). The patient will also follow up in [Show Less]