Assignment: Clinical Case Study Part Two Discussion
Assignment: Clinical Case Study Part Two Discussion
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Primary Diagnosis
Hypothyroidism (ICD 10-E03. 9): My primary diagnosis is hypothyroidism based on the patient’s presenting symptoms and physical findings. Pertinent positive findings include symptoms of fatigue, low energy levels, general body weakness, hypersomnolence, weight gain, cold intolerance, progressive depressive symptoms, and cramping of calf muscles. Physical findings of dry skin, a firm thyroid gland, coarse and thick hair, and being overweight pointed to hypothyroidism. However, there were negative findings of a decreased appetite, mental impairment, labile emotions, blurred vision, hoarseness, and throat fullness which are symptoms of hypothyroidism (Patil & Jialal, 2019). Thyroid function test reveals an elevated level of Thyroid-stimulating hormone of 6.770 uIU/mL and a low level of free circulating thyroxine hormone of 0.62 ng/dL, indicating hypothyroidism.
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Treatment Plan
Medication: Levothyroxine 25 mcg, orally, once a day for the first six weeks. It is a thyroid product that will promote growth and maturation of thyroid tissues and support normal metabolism and growth (Benvenga & Carlé, 2019). Levothyroxine is administered to replace or supplement the insufficient endogenous Thyroxine and is the thyroid product of choice in patients diagnosed with hypothyroidism. The dose should be modified after 6-8 weeks until the desired TSH levels are achieved (Benvenga & Carlé, 2019).
Continue medications: Continue with Bisoprolol-HCTZ 2.5mg/6.25mg to manage elevated blood pressure. Prozac 20mg to treat depressive symptoms and Multivitamin, B-Complex, and Vitamin D3 400IU to supplement nutritional intake.
Additional Tests: Thyroid ultrasound to visualize and detect for nodules in the thyroid gland, which could suggest the presence of goiter (Peterson, 2016).
Health Education: Consumption of foods fortified with Iodine to facilitate normal thyroid function (Patil & Jialal, 2019). I will advise the patient to adhere to treatment therapy to facilitate achievement of the desired TSH levels. Counseling on the consumption of a healthy and balanced diet to promote a healthy weight, boost the immune system, and improve brain function (Patil & Jialal, 2019). I will advise the patient to engage in daily physical exercises to promote and maintain a healthy weight and boost brain function to lower the depressive symptoms.
Referral: The patient will be referred to an endocrinologist if she is unresponsive to treatment, and the desired TSH levels are not achieved after repeated administration of Levothyroxine (Peterson, 2016). She will also be referred to if she develops a cardiac disease, another endocrine disorder, or has difficulty in swallowing.
Problem List
- Fatigue
- General body weakness
- Depressive symptoms
- Hypersomnia
- Overweight
- Cold intolerance
Changes in the Treatment Plan
Discontinue Medications: Stop Calcium supplements since they interact with Levothyroxine. Calcium interferes with the absorption of Levothyroxine (Benvenga & Carlé, 2019).
Follow-Up Plan
Follow-up visits will be after every six weeks. The first visit will involve measuring the TSH and FT4 levels to evaluate if they are within the desirable range. If the desired level is not achieved, the Levothyroxine dose will be increased to 50 mcg per day (Benvenga & Carlé, 2019). The dosage will be increased to a maximum of 125 mcg in the subsequent visits depending on the TSH and FT4 levels (McAninch & Bianco, 2016). After the dose has been stabilized, she will be monitored for symptoms of Levothyroxine overdose such as palpitations, fatigue, nervousness, headache, insomnia, tremors, tachycardia and atrial fibrillation (McAninch & Bianco, 2016). Once the desired Thyroid function levels have been achieved, monitoring of FT4 will be done annually.
References
Benvenga, S., & Carlé, A. (2019). Levothyroxine Formulations: Pharmacological and Clinical Implications of Generic Substitution. Advances in therapy, 1-13.
McAninch, E. A., & Bianco, A. C. (2016). The history and future of treatment of hypothyroidism. Ann Intern Med, 164(1), 50-56.
Patil, N., & Jialal, I. (2019). Hypothyroidism. In StatPearls. StatPearls Publishing.
Peterson, M. E. (2016). Diagnosis and management of iatrogenic hypothyroidism. August’s Consultations in Feline Internal Medicine, 7, 260-269.