Reply to Amanda

Do you take any medications?

Some medications (Lithium) are notorious for causing hypothyroid.

Have you ever been diagnosed with a thyroid disorder?

Surgeries to the thyroid may result in hypothyroid.

Are you allergic to anything?

Relevant to treatment regimen.

Have you experienced any significant life changes? Additional stress etc?

Depression may manifest similar symptoms.

PE:

Hypothyroidism is six times more common in women than men, and is most common in older women (Carson, 2009). A thorough physical assessment should be completed. Clinical signs and symptoms may include paleness, brittle appearing hair and skin, elevated blood pressure, and bradycardia (Carson, 2009). The patient may have a “puffy” appearance to her face, irregular periods, and report sustained fatigue (Roberts et al, 2009).

Differential Diagnoses

Anemia, Depression

Diagnostics

TSH – Will be elevated in Hypothyroid

Free T4 – Result will be low in Hypothyroid

Cholesterol – Often elevated with Hypothyroid

CBC – To rule out anemia

CMP – To monitor other electrolytes

EKG – to assess for any blocks, prolonged QRS, or electrolyte abnormalities

Treatment

Patients with symptomatic hypothyroidism should be treated to prevent long-term complications (Roberts et al, 2004) Depending on the results of her TSH & T4 I would initiate a daily regimen of Levothyroxine. 4-6 weeks after the initiation of Levothyroxine I would recheck the patients TSH. After the TSH has reached a therapeutic level – I would recheck it again in 6 months.

References

Carson, M. (2009). Assessment and management of patients with hypothyroidism. Nursing Standard (through 2013), 23(18), 48-56; quiz 58. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/219883523?accountid=167104 (Links to an external site.)Links to an external site.

Roberts, C. G. P., & Ladenson, P. W. (2004). Hypothyroidism. The Lancet, 363(9411), 793-803. doi:http://dx.doi.org/10.1016/S0140-6736(04)15696-1

reply to Quiana

1. What additional questions should you ask the patient and why?

Some questions include:

• How much weight has been gained? What kinds of meals/foods do you typically take? Do you exercise?
• Quantifying the amount of weight provides perspective. A gain of 5 lbs does not carry the urgency that a 20 lb weight gain does. Asking about her lifestyle habits can offer some insight into factors that can aggravate what sounds like hypothyroidism. This creates teachable opportunities for improving lifestyle habits.
• Are you still menstruating and if so, how regularly?
  • This can rule out pregnancy or hormone changes that precipitate menopause. Also, with hypothyroidism, this condition can disrupt a normal menstrual cycle. For a woman in menopause, hypothyroid symptoms can be masked or ignored when it is assumed that it is a lack of ooestrogen that is causing her concerns (Baisier, Hertoghe, & Eeckhaut, 2000).
• Bowel habits, specifically any problem with constipation?
  • (Chaker, Bianco, Jonklaas, & Peeters, 2017)
• Any hx of depression?
  • Her reported complaints are common findings for hypothyroid but they can also be related to depression. Though the rate of depression in hypothyroid patients is >60% (Bathla & Singh, 2016), the patient should be screened for depression. Her symptoms could be psychosomatic.

1. What should be included in the physical examination at this visit?

• Included items to address are skin for dryness, hair for thinning or irregular growth pattern, eyes for exopthalmus, neck/throat and thyroid for possible goiter, cardiac sounds for bradyarrhythmias, and also for peripheral manifestations like delayed relaxation of deep tendon reflexes (Chaker, et al., 2017).

1. What are the possible differential diagnoses at this time?

• Hypothyroidism
• Depression
• Anemia
• What tests should you order and why?
• TSH and free T3 and T4
• EKG
• CMP
• CBC
• Lipid Panel
• A depression screen can be done in office

Hypothyroidism can increase lipids and alter cardiac function (Chaker, et al., 2017). EKG may reveal cardiac abnormalities. CBC can reveal anemia. The metabolic panel can reveal diabetes or problems with hepatic or renal function. Hypothyroidism continues to be researched as far as the specific link to renal and hepatic dysfunction (Chaker, et al., 2017). The depression screen serves, like the other lab orders, to exclude causes of her symptoms. The most obvious test is a thyroid panel. To assess the circulating amount of hormone in the body is to judge her thyroid function.

1. How should this patient be managed?

• Pending the diagnosis, the patient should be encouraged to complete all lab work in a timely fashion. Since these labs can be resulted within 24hrs, if not same day, that would be my biggest priority for completion. For hypothyroidism, pending the thyroid results, the patient should start on hormone replacement with a drug like levothyroxine. Often, levothyroxine 50-100mcg is a starting dose (Dunphy, Winland-Brown, Porter, & Thomas, 2015), it should be taken daily, on an empty stomach, in the morning. She should return in about 1 mo to reassess symptoms and lab value. If the patient is difficult to manage, due to comorbid conditions or lack of therapeutic response, endocrine may be consulted.

References

Baisier, W. V., Hertoghe, J., & Eeckhaut, W. (2000). Thyroid insufficiency. is TSH measurement the only diagnostic tool? Journal of Nutritional & Environmental Medicine, 10(2), 105-113. Retrieved from https://prx-herzing.lirn.net/login?url=https://search.proquest.com/docview/215623935?accountid=167104

Bathla, M., & Singh, M. (2016). Reply to “how prevalent are depression and anxiety symptoms in hypothyroidism?”. Indian Journal of Endocrinology and Metabolism, 20(6) doi:http://dx.doi.org/10.4103/2230-8210.192913

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550-1562. doi:http://dx.doi.org/10.1016/S0140-6736(17)30703-1

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: The art and science of advanced practice nursing, (4th ed.). [VitalSource Bookshelf version].  Retrieved from https://bookshelf.vitalsource.com/books/9780803655621

Students will complete an APA paper about the following case study.  The provided case study represents ethical issues of historical interest.

Case Study

A nurse has sued Memorial Hospital, charging that she was demoted after complaining about a heart surgeon tossing bloody tissue at her during an operation. The eight-page complaint filed Friday in U.S. District Court by Sonja Morris alleges that Dr. Bryan Mahan tossed the 4-by-6-inch piece of tissue at her, hitting her on the leg during an open-heart surgery in August 2008. She contends Mahan made a joke about it to the other surgeons, saying, “Oh (expletive), I hit her. Can we get cultures on that?” Morris said she felt humiliated as the other surgeons chuckled. Mahan could not be reached for comment Friday afternoon.

Morris claims that the incident was part of a pattern of harassing behavior by Mahan toward her. She also alleged that in June 2008, Mahan came up behind her and hit her in the head. She told him to stop, but two weeks later, he did it again, the suit alleged. Again she asked him to stop.

Chris Valentine, a spokesman for the hospital, declined to comment on the lawsuit. “Obviously, because it’s in legal hands, we’re not in a position to comment,” he said. Mahan is the chairman of cardiac and thoracic medicine at Memorial. He is not named as a defendant in the lawsuit. Morris has worked at the hospital as a nurse since June 1999. She has been a member of the heart surgery team since October 2007.

The incident with the bloody tissue occurred on Aug. 28, 2008, after normal working hours during an operation in which doctors were doing a procedure known as a pericardiectomy. The surgery involved removing a protective layer of tissue from the heart. Morris contends that was the bloody tissue that Mahan tossed at her. She said she was standing at a work station about 15 feet away from the operating table. Because the operation was still in progress, she was unable to immediately clean the part of her leg that the tissue hit. She filed a complaint about the incident but said that resulted in no disciplinary action.

On Dec. 10, she filed a notice of claim against Mahan and the hospital. Her complaint to the U.S. Equal Employment Opportunity Commission alleged that she was subjected to a hostile work environment because of her gender. Seven days later, she said hospital administrators removed her from the heart surgery team, considered a prestigious position, and transferred her to the main operating room. The suit alleged that this action violated her First Amendment rights to petition the hospital to correct something she considered wrong.

Ensslin, J.C. (2009, June 6). Nurse sues Memorial, claims surgeon threw human tissue at her. The Gazette. Retrieved from http://gazette.com/nurse-sues-memorial-claims-surgeon-threw-human-tissue-at-her/article/57418

Morris v. City of Colorado Springs, 666 F.3d 654 (2012)  LINK

Answer the following questions:

1. What are the facts of the case? This should include: what do we need to know, who is involved in the situation, where does the ethical situation take place, and when does it occur?
2. What is the precise ethical issue in regards to autonomy, nonmaleficence, beneficence, fidelity, and justice?
3. Identify the major principles, rules, and values of the case.  Values are sets of beliefs about good and bad, right and wrong, and about many other aspects of living and interacting in the society with others. A principle is a personal rule that governs personal behavior. A rule is generally imposed by a figure of authority, and used to guide and govern people.
4. Is there legal ground for this case, if so what? Who is at fault? What legal action should be taken?
5. Are there alternative to the actions completed in this case by both the nurse, physician, and healthcare facility? Do you feel the physician and nurse were following hospital protocol?
6. If you were a member of the ethics committee at this facility, what actions or changes would you recommend changing? Why?

For the case study, an APA formatted paper should be used, and needs to include a title page, level headings, references and citations. This assignment should include at least 2 references and should be at least four pages in length. Students should address the proposed questions providing ample detail, examples, and additional support.

Assignment Expectations:

• Length:
  • At least four pages in length; answers must thoroughly address each question in a clear, concise manner;
• Structure:
  • Reference page required
  • address each question in a numbered list
• References:
  • At least 2 references required
• Format:
  • save your assignment as a Microsoft Word (.doc or .docx), Open Office (.odt) or rich text format (.rtf) file type