NR 511 Week 6 Case Study Discussion; Part Two/NR 511 WEEK 6 CASE STUDY DISCUSSION PART 2

NR 511 Week 6 Case Study Discussion: Part Two Now, assume that you sent your patient for labs and she returns the following day, as instructed, to review the results. CBC with differential WBC 8.6 x10E3/uL RBC 4.44 x 10E6/uL Hemoglobin 14.0 g/dL Hematocrit 41.2% MCV 93fL MCH 31.5 pg MCHC 34.0 g/dL RDW 13% Platelet 241 x 10E3/uL Neutrophils % 67% Lymphocytes % 22% Monocytes % 8% Eosinophils % 3% Basophils % 0% Absolute Neutrophils 5.7 x 10E3/uL Absolute Lymphocytes 1.9 x 10E3/uL Absolute Monocytes 0.7 x 10E3/uL Eosinophils Absolute 0.3 x 10E3/uL Basophile Absolute 0.0 x 10E3/uL Immature Grans % 0% Absolute Immature Grans 0.0 x 10E3/uL TSH with Reflex to FT4 TSH 6.770 uIU/mL FT4 0.62 ng/dL PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago) 1. What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pertinent positives and negatives from the case) 2. Identify the corresponding ICD-10 code. 3. Provide a treatment plan for this patient's primary diagnosis which includes: o Medication* o Any additional testing necessary for this particular diagnosis* o Patient education* o Referral 4. Provide an active problem list for this patient based on the information given in the case. 5. Are there any changes that you would make to the patient's overall plan at this time? Must provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions. 6. Provide an appropriate follow-up plan (include any additional testing that you feel is necessary and include an EBM argument). *If part of the plan does not warrant an action, you must explain why. ALL medication and testing decisions (or decisions not to treat with medication or additional testing) MUST be supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if handing a script to the patient in the office. Answer: Week 6 Discussion: Part 2 After reviewing the lab work the primary diagnosis would be hypothyroidism with anemia and depression as secondary effects of the disease process. Her TSH was elevated at 6.770 mIU/L (0.35-5.0 mIU/L normal range) and her FT4 of .62 ng/dL (0.7-1.53 ng/dL). An elevation of TSH and decrease in FT4 are indicative of hypothyroidism (Kalra, & Khandelwal, 2015). The results of her CBC were not indicative of anemia at this time, she is low normal but is normal nonetheless with a RBC of 4.4 with a normal range of 4.2-5.4. Again, hypothyroidism is most likely the cause of her fatigue and other related symptoms she is presenting with (Stauder, Valent, & Theurl, 2018). PHQ-9 score of 10 indicates moderate depression and utilization of clinical judgment should be done to determine treatment options (Manea, Gilbody, & McMillan, 2015). Hypothyroidism is my primary diagnosis for the patient presented with a corresponding ICD code of E0.39 Synthroid (levothyroxine) would be the selected treatment. Indicated dosage should start at 1.6mcg/kg PO qd and adjustments should be made by 12.5-25 mcg/day q4-6 weeks with a max dose of 300 mcg/day, generally a dose of 50-200 mcg/day is used to normalize a TSH level (Epocrates, 2018). The patients weight is 180 lbs. converted to kg is 81.8 kg so the starting dose would be 130 mcg qd however since Synthroid is supplied in a 125 or 137 mcg tablet I would suggest a 125 mcg tablet at this time. A full replacement dose is recommended in individuals newly diagnosed and are otherwise healthy persons. TSH levels should be drawn ever 6-8 weeks to determine if treatment is effective and if adjustments need to be made, once the patient is in euthyroid. After a patient is therapeutic a TSH and T4 can be drawn every six months (Jonklaas, Bianco, Bauer, Burman, et. al., 2014). Written as a prescription format: Synthroid (Levothyroxine) 125mcg Tablet One Tablet Daily 30 minutes before breakfast Dispense # 30 Refill one time (Epocrates, 2018). Important factors to educate the patient about Synthroid include taking the medication 30 minutes or longer prior to eating as well as taking with other medications that could interfere with the medication absorption and effectiveness (Epocrates, 2018). Problem list includes: • Hypertension • Depression • Hypothyroidism • High risk for Hyperlipidemia, Diabetes and Cardiovascular disease due to strong familial history. Other testing should include a lipid panel since hypothyroidism can have many secondary disease processes with hyperlipidemia being one of them and with a significant family history of HLD it would be advantageous to have these results available. I would also like to determine the cause of her newly diagnosis of hypothyroidism such as an ultrasound of her thyroid and possibly consult to a endocrinologist. I would also order a TPO (thyroperoxidase antibodies) to determine if the cause is Hashimotos as autoimmune disease that affects the thyroid (Caturegli & Remigis, 2014). At this time I would also discuss with the patient about considering increasing her Prozac dosage to help with the depression symptoms but also keeping in mind depression is also another secondary cause of the hypothyroidism. The Prozac could be increased at this time or to wait until the Synthroid has become effective in relieving her current symptoms. As a practitioner I would prefer to use one treatment at a time to determine which one is the most effective (Kom & Reynolds, 2017). I would also schedule a follow up with the patient at approximately 3-4 weeks in the office. I would also inform the patient if her symptoms should worsen to call the office or go to the emergency room in case of an emergency. Lastly, I would review her TSH and T4 and other lab work and diagnostic tests that should be completed to determine if there are any other disease processes causing the hypothyroidism and to see if the treatment is effective or needs to be adjusted. Caturegli, A. & Remigis, R. (2014). Hashimoto thyroiditis: clinical and diagnostic criteria. Autoimmunity Reviews, 13(4-5). 391-397. Epocrates Athena Health. (2018). Epocrates Drug. Retrieved from Jonklaas, J., Bianco, A. C., Bauer, A. J., Burman, K. D., Cappola, A. R., Celi, F. S., … Sawka, A. M. (2014). Guidelines for the Treatment of Hypothyroidism: Prepared by the American Thyroid Association Task Force on Thyroid Hormone Replacement. Thyroid, 24(12), 1670–1751. Kalra, S., & Khandelwal, S. K. (2015). Why are our hypothyroid patients unhappy? Is tissue hypothyroidism the answer? Indian Journal of Endocrinology and Metabolism, 15(Suppl2), S95–S98. Kom, R., & Reynolds, C. (2017). Management of depression in older adults. JAMA. 2017;317(20):2114–2122. http://doi:10.1001/jama.2017.5706 Manea, L., Gilbody, S., & McMillan, D. (2015). A diagnostic meta-analysis of patient health questionnaire-9 (PHQ-) algorithm scoring method as a screen for depression. General Hospital Psychiatry, 37(1). 67-75. Stauder, R., Valent, P., & Theurl, I. (2018). Anemia at older age: etiologies, clinical implications, and management. Blood 2018, 131. 505-514. doi: ICD10.Diagnosis codes. (2018). Retrieved from