Unit 3 Discussion Hyperthyroidism. Due 1-23-23. 1200 words. 4 references.

Unit 3 Discussion Hyperthyroidism. Due 1-23-23. 1200 words. 4 references.

Read the following case study and answer the posed questions:

Case #1:

History: A 65 year old housewife complains of progressive weight gain of 40 pounds in 1 year, fatigue, dizziness, sluggish memory, slow speech, deepening of her voice, dry skin, constipation, and cold intolerance.

Physical examination: Vital signs: temperature 96.4oF, pulse 68/minute and regular, BP 108/60, weight 170 lbs, height 5 feet, puffy face, pale, cool, dry skin. The thyroid gland is not palpable, deep tendon reflex time is delayed.

Laboratory studies: CBC and differential WBC are normal. The serum T4 concentration is 3.4 ug/dl (N=4.5-12.5), the serum TSH is 0.9 uU/ml (N=0.2-3.5), and the serum cholesterol is 275 mg/dl (N<200).

1. What is the likely diagnosis and what symptoms made you consider that diagnosis? 

2. Which lab data supported the diagnosis? 

3. Explain-Hypothalamic-Pituitary-Thyroid axis and interrelationship.

Case #2:

J.R. is a 58-year old man who presented with a 6-week history of polyuria, polydipsia, polyphagia, weight loss, fatigue, and blurred vision. A random glucose test performed on day of his visit and was 359 mg/dl. The patient denied any symptoms of numbness, tingling in hands or feet, dysuria, chest pain, cough or fevers. He had no prior history of diabetes and no family history of diabetes.

Admission non-fasting serum glucose 268 mg/dl (N=<180 mg/dl), HbA1c 9.6% (N=4-6.1%). Electrolytes, BUN and creatinine were normal. Physical examination revealed weight of 190 pounds, height 5'6.5" . The rest of the examination was unremarkable, i.e., no signs of retinopathy or neuropathy.

1. What are the mechanisms of blurred vision which was part of his initial symptoms?

2. Are there correlations between his abnormal blood chemistries and his other symptoms?

3. Identify the cardiovascular and microvascular risk factors in the history, physical examination, and laboratory data in this patient.

Cite current research findings, national guidelines, and expert opinions and controversies found in the medical and nursing literature to support your position.

Responses need to address all components of the question, demonstrate critical thinking and analysis, and include peer reviewed journal evidence to support the student’s position.

Please be sure to validate your opinions and ideas with citations and references in APA format.

Please review the rubric to ensure that your response meets the criteria.

Estimated time to complete: 2 hours

Use information below to respond to the questions.

Case #1:

History: A 65 year old housewife complains of progressive weight gain of 40

pounds in 1 year, fatigue, dizziness, sluggish memory, slow speech,

deepening of her voice, dry skin, constipation, and cold intolerance.

Physical examination: Vital signs: temperature 96.4oF, pulse 68/minute

and regular, BP 108/60, weight 170 lbs, height 5 feet, puffy face, pale, cool,

dry skin. The thyroid gland is not palpable, deep tendon reflex time is

delayed.

Laboratory studies: CBC and differential WBC are normal. The serum T4

concentration is 3.4 ug/dl (N=4.5-12.5), the serum TSH is .9 uU/ml (N=0.2-

3.5), and the serum cholesterol is 275 mg/dl (N<200).

What is the likely diagnosis and what symptoms made you consider

that diagnosis?

The likely diagnosis is hypothyroidism from the deficient thyroid gland not

producing enough of the thyroid hormone (TH). Hypothyroidism usually

involving women 1.4% to 2.0% over men at 0.1% to 0.2% (Elliott, 2000).

Hypothyroidism usually affects women over 50 with an increase with a range

between 40 and 50 years of age (Elliott, 2000). The symptoms for

hypothyroidism are fatigue, increased sensitivity to cold, constipation, dry

skin, weight gain, puffy face, hoarseness, muscle weakness, elevated blood

cholesterol level, pain and swelling in joints, irregular menstrual periods,

thinning hair, slowed heart rate, depression, memory problems, an enlarged

thyroid gland (goiter) (McCance, Huether, Brashers, & Rote, 2014). The 65-

year-old housewife has clinical signs in the last year complained of several

symptoms over the past year. The features suggesting hypothyroidism are

female, deep voice, dry skin, constipation, fatigue, and deep tendon reflex is

delayed. The patient is probably has secondary hypothyroidism. It is caused by traumatic brain injury, subarachnoid hemorrhage, or pituitary infarction.

The quality of life is discussed during the visit to determine how symptoms

are perceived (Carson, 2009). The patient may have a pituitary malfunction,

or hypothalamic malfunction (McCance et al., 2014). A complete history

would help to identify other endocrine concerns such as diabetes. Which lab data supported the diagnosis?

There are several hormones to check for with the suspected

hypothyroidism. The lab data provides the most important concern is the

thyroid-stimulating hormone (TSH) and the thyroxine (T4), which is produced

by the thyroid gland. The normal range for T4 is 75 to 195 ng/dl (1.1 to 3

nmol/dl), and TSH is 0.4 to 4.0 mU/l. The patient levels are the TSH are low

being 0.9 uU/ml, and T4 is 3.4 ug/dl (N=4.5-12.5) along with an elevated

cholesterol level of 275 mg/dl (N<200). The T4 and T3 levels in the blood are

controlled by the THS hormone released into the system in response to the

metabolic demand affecting many organs such as hypogonadism or growth

hormone (Elliott, 2000). Explain-Hypothalamic-Pituitary-Thyroid axis and interrelationship.

The hypothalamic-pituitary-thyroid axis and interrelationship affect

approximately 20 to 30% of individuals with a diagnosis of depression with

altered hypothalamic-pituitary-thyroid (McCance et al., 2014). It is

responsible for the regulation of metabolism and responds to stress. Patients

have increased level of thyrotropin-releasing hormone (TRH). Exhibiting decrease in thyroid-stimulating hormone (TSH). The release of hormone

occurs during the nighttime hours and early morning hours (McCance et al.,

2014). The thyroid gland is the main regulator for the pituitary glycoprotein

hormones (Mariotti & Beck-Peccoz, 2016). Case #2:

J.R. is a 58-year old man who presented with a 6-week history of polyuria,

polydipsia, polyphagia, weight loss, fatigue, and blurred vision. A random

glucose test performed on day of his visit and was 359 mg/dl. The patient

denied any symptoms of numbness, tingling in hands or feet, dysuria, chest

pain, cough or fevers. He had no prior history of diabetes and no family

history of diabetes.

Admission non-fasting serum glucose 268 mg/dl (N=<180 mg/dl), HbA1c

9.6% (N=4-6.1%). Electrolytes, BUN and creatinine were normal. Physical

examination revealed weight of 190 pounds, height 5'6.5" . The rest of the

examination was unremarkable, i.e., no signs of retinopathy or neuropathy.

What are the mechanisms of blurred vision which was part of his

initial symptoms?

The initial symptoms with diabetes and vision are related to diabetic

neuropathy. Diabetes is more prevalent with the elderly above 65 years of

age. The early recognition of diabetes and strict control A1C levels and

regular screenings for diabetic retinopathy will help decrease the risk of

complications of progression, leading to loss of vision. The associated risk is

the development of the microvascular diseases such as retinopathy,

nephropathy, and neuropathy (McCance et al., 2014).

Are there correlations between his abnormal blood chemistries and

his other symptoms?

There is a significant correlation with symptoms and lab results. The

patient is obese, weighing at 190 pounds putting him at risk for diabetes with a BMI of 30.66. The patient may still have a disposition for insulin resistance

developing to diabetes. He has an elevated A1C level of 9.6%, with a normal

range being 8.0 %. The elevated blood sugar was not fasting. It would be

essential to ask what he had eaten and when? The symptoms may be the

initial symptoms of the development of type 2 diabetes, signaling a downregulation

of the insulin receptors (McCance et al., 2014). The patient has

classic symptoms of polyuria and polydipsia, fatigue, and vision changes

(McCance et al., 2014). The blood pressure would be helpful to assist with

other complications related to symptoms. Identify the cardiovascular and microvascular risk factors in the

history, physical examination, and laboratory data in this patient.

The microvascular risk factors identified in patient history. The possible

development of diabetic retinopathy with severe elevated hyperglycemia.

Oxidative stress can play a role in hyperglycemia causing damage to cells.

The formation of damage to both small and large vessels contributes to

atherogenesis. Chronic insulin resistance, hyperinsulinemia, and dyslipidemia

impact the making of reactive oxygen species (ROS), causing harmful effects

of oxidative stressors (McCance et al., 2014). The injuries or complications

are late affecting of diabetes mellitus (McCance et al., 2014). This will also

increase risk factors for coronary artery disease (CAD) rises with length of

diabetes disease.

Christine. You did a great job with your post. I do agree with your discussion

on hypothyroidism. The symptoms of fatigue and weight gain can be

indicators to Hashimoto’s thyroiditis. It should be considered upon exam a

review of labs for anti-thyroid microsomal antibodies or anti-thyroid

peroxidase (TPO) antibodies (Amino & Akamizu, 2017). Additional lab values

to review are anti-thyroglobulin antibody I the thyroid gland findings of

cytological information for lymphocytic infiltration with patient visit (Amino &

Akamizu, 2017). The patient may present with or without a goiter formation

or thyroid disfunction with positive antibodies consideration for Hashimoto’s

thyroiditis. Obtaining a complete family history for thyroid disease will help

in early diagnosis. Hashimoto thyroiditis is genetically susceptible individuals

with a larger iodine intake, selenium deficiency, smoking, chronic hepatitis C,

and interferon-alpha (McCance et al., 2014). Most patients will require

monitoring thyroid levels every 3-6 months and treatment of levothyroxine

until levels are stable. The patient will be monitored for hyperthyroidism

(Amino & Akamizu, 2017). Case 2

The care for controlling blood sugars in diabetes is essential to reduce

complications from the disease. Diabetes is the leading cause of blindness

from uncontrolled blood sugars. Retinopathy is one of the complications from

diabetes with a symptom of dry eyes. Diabetic retinopathy may be enhanced

by surgery, pregnancy, hypertension, and poor blood sugar control. (Dugan, Pfotenhauer, Young, & Shubrook, 2017). Early detection and regular

screening for diabetic retinopathy and macular edema after diagnosis of

diabetes. J.R. is at increased risk of development of microvascular disease

and development of retinopathy with A1C of 9. 6 %. The management to

control blood sugar will help minimize the risk of complications.

Response 2

Marie-Berline

You did a great job on your post. I do agree in case study 1 with her clinical

symptoms over the last year. The symptoms usually start to affect the

person over months or years with a varying degree of symptoms (McCance

et al., 2014). Although, one visual symptom of swelling around the eyes may

be a characteristic sign of myxedema which is a close relationship to Graves

disease (McCance et al., 2014). I do believe additional information would

assist if hands, feet, and edema to rule out Myxedema. The patient being

female, elderly it is more frequent in the United States (McCance et al.,

2014) Her initial lab work checking estriol levels and gather information on

libido, for altered metabolism of estrogens and androgens. The house wife

She has central hypothyroidism with goal to improve normal TSH levels.

Case study 2

I enjoyed reading your post. I went back to look and study. I do think

additional information is necessary to identify a complete history. The symptoms the patient complained about during the visit. I would like to know

about changes in medications. I do wonder if he has COPD with a steroid

inhaler or chronic pain receiving steroid injections over several months. He

would need to follow more frequently with a family history. The risk of

complications increases with comorbidities. The patient is an increased risk

to developing additional complications from elevated A1C 9.6%. The patient

could develop microvascular disease, retinopathy, neuropathy, nephropathy,

skin conditions, and hearing impairment. The symptoms can be controlled

with managing blood sugar to slow down the damage of diabetes. His BMI is

30.66 which is just above the normal range (McCance et al., 2014). I would

encourage exercise to reduce weight, and exercise increases insulin

sensitivity advancing glucose tolerance with the caloric intake (McCance et

al., 2014). I would start with oral hypoglycemic medications and reevaluate

in 3 months with labs for A1C and kidney function. If unresponsive he may

need insulin therapy for beta-cell function (McCance et al., 2014).

References

Amino, N., & Akamizu, T. (2017, July 17). Hashimoto’s Thyroiditis. Endotext [Internet].

Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK285557/table/tydhashimotos.

someclinic/

Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing

Standard (through 2013), 23(18), 48-56. Retrieved from https://prx-