NU 665 Week 6 Assignment 1: iHuman Simulation

Sample Answer for NU 665 Week 6 Assignment 1: iHuman Simulation

Assessment

• Hyperthyroidism, graves’ disease ICD10: – graves’ disease is the most attributable cause of hyperthyroidism with an onset at any age in both genders. However, women aged 30- 50 years are at a higher risk (Kahaly et al., 2018). As an autoimmune disorder affecting the thyroid gland, it’s associated with the loss of tolerance to TSH (thyrotropin) receptors that leads to excess and uncontrolled production of thyroid hormones (T4, T3 and thyroxine) and thyroid growth (Kahaly et al., 2018). Precipitating factors include; smoking, stress, iodine exposure, and infection. Although presentation largely depends on  severity, agent of onset, and duration, elderly patients often present with nonspecific signs and symptoms including; weight loss, fatigue, atrial fibrillation, weight loss, palpitations, tremors, and heat intolerance. Additional symptoms include insomnia, dyspnea, anxiety, nervousness, pruritus, and muscle weakness (Kahaly et al., 2018). Physical exam will demonstrate signs of heart failure, tachycardia, fine tremors, hyperreflexia, and palmar erythema. While this patient’s history and physical exam findings are consistent with graves’ disease, diagnostic findings with an elevated FT4, thyroid scan consistent with graves’ disease, suppressed TSH, and elevated thyroid stimulating immunoglobulins supports this diagnosis.
• Goiter, unspecified ICD10:E04.9 – describes enlargement of the thyroid gland attributed to iodine deficiency and inflammatory disorders of the thyroid gland (Can & Rehman, 2020). Patients may report a history of thyroid surgery or disease, familial history of thyroid disease, or previous exposure to head and neck irradiation.
• Generalized anxiety disorder (GAD), unspecified ICD10:F41.1 – GAD is more prevalent in women compared to men. Its associated risk factors include; comorbid psychiatric disorders, low socio-economic status, trauma history, substance abuse history, being separated, widowed, or divorced (DeMartini, Patel & Fancher, 2019). Patients often report symptoms of fatigue, restlessness, concentration difficulty, sleep disturbance, muscle tension, irritability, excess worry and anxiety over everyday events that is difficult to control, resulting in distress performing everyday tasks for atleast 6 months (DeMartini, Patel & Fancher, 2019). However, these symptoms must not be attributable to medication physiologic effects, underlying medication conditions such as hyperthyroidism, an underlying mental disorder, or drug abuse (DeMartini, Patel & Fancher, 2019). Considering that the patient’s symptoms were attributed to graves hyperthyroidism, GAD is a less likely diagnosis.
• Insomnia, unspecified ICD10:G47.00 – patients with insomnia report difficulty maintaining or initiating sleep, daytime dysfunction, or early morning awakening for atleast six months (Patel, Steinberg & Patel, 2018). Its most identified risk factors include; gender (women) and advanced age. It results in an increase the occurrence of accidents and decreased work productivity. Patients often report impaired memory, concentration, attention, fatigue, impaired occupational, family, social, or academic performance, decreased motivation, or aggression (Patel, Steinberg & Patel, 2018). However, the aforementioned symptoms must not be explained by another sleep, psychiatric, or physical disorder.

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NU 665 Week 8 Assignment 1: i-Human Simulation

Final Diagnosis: hyperthyroidism, graves’ disease.

Management Plan

Pharmacology

• Propylthiouracil (PTU) 50-150mg q8h PO for 12 months (Kahaly et al., 2018).
• Atenolol 25mg PO q12hr

Non-Pharmacology

• Discuss the need for medication compliance to maintain a euthyroid state (Kahaly et al., 2018).
• Discuss the complications of graves disease, including signs, symptoms and contributing/worsening factors
• Emphasize the essence of maintaining a good sleep hygiene routine to improve her quality of life (QoL)
• Discuss the effects of alcohol consumption and tobacco smoking on graves orbitopathy and encourage the patient to continue cessation (Kahaly et al., 2018).

Diagnostics

• No additional diagnostics needed in this visit.

Consults/Referrals

• Referral to an endocrinologist for further evaluation and management

Patient Education

• Inform the patient how the dosage will be tapered gradually until the attainment of a euthyroid state with a normal TSH
• Inform the patient the essence of the prescribed beta blocker (atenolol) in managing the adrenergic effects (Kahaly et al., 2018).
• Educate the patient about the effects of treatment on the quality of life (QoL) and the need for psychosocial support throughout management.
• Inform and discuss with the patient about other management options; surgical resection or thyroid ablation using radioactive iodine and support her choice.

Follow Up

• Patient to return in two weeks to evaluate treatment response and need for dose adjustments.

References

Can, A. S., & Rehman, A. (2020). Goiter.

DeMartini, J., Patel, G., & Fancher, T. L. (2019). Generalized anxiety disorder. Annals of internal medicine, 170(7), ITC49-ITC64. https://doi.org/10.7326/AITC201904020

Kahaly, G. J., Bartalena, L., Hegedüs, L., Leenhardt, L., Poppe, K., & Pearce, S. H. (2018). 2018 European Thyroid Association guideline for the management of Graves’ hyperthyroidism. European thyroid journal, 7(4), 167-186. https://doi.org/10.1159/000490384

Lee, S. Y., & Pearce, E. N. (2023). Hyperthyroidism: a review. JAMA, 330(15), 1472-1483. https://doi.org/10.1001/jama.2023.19052

Patel, D., Steinberg, J., & Patel, P. (2018). Insomnia in the elderly: a review. Journal of Clinical Sleep Medicine, 14(6), 1017-1024. https://doi.org/10.5664/jcsm.7172