Question

Group 2 Scenario:

You are working in a community outpatient clinic where you perform the intake assessment on R.M., a 38-year-old woman who is attending graduate school and is very sedentary. Her chief complaint is overwhelming fatigue that is not relieved by rest. She is so exhausted that she has difficulty walking to classes and trouble concentrating when studying. She reports a recent weight gain of 15 pounds over 2 months without clear changes in her dietary habits. Her face looks puffy, she has experienced excessive hair loss, and her skin is dry and pale. She complains of generalized body aches and pains with frequent muscle cramps and constipation. You notice she is dressed inappropriately warm for the weather.
Vital Signs
Blood pressure 142/84 mm Hg
Heart rate 52 beats/min
Respiratory rate 12 breaths/min
Temperature 96.8 ° F (36 ° C)

Laboratory Test Results
TSH 20.9 mU/L (2-10 mU/L)
TRH 18.8 ng/dL (2-10 ng/dL)
T 3 24 mU/L (70-205 ng/dL)
Free T 4 0.2 ng/dL (0.8-2.4 ng/dL)

1. What are the top priority assessments (specific to this patient)? Include at least 3 with rationale.

2. Interpret R.M.'s laboratory results.

3. The family practitioner prescribes levothyroxine (Synthroid) 1.7 mcg/kg body weight/day. Patient weighs 130 pounds. What is the daily dose in milligrams?

4. What teaching will you review regarding medication? List 5 key teaching points with details.

5. Why are we concerned with Myxedema coma? What teaching will you provide for prevention of myxedema coma?

Answer 1

1

• Assessment of the patient includes questions about weight gain,fatigue ,cold intolerance,skin changes such as increased dryness and constipation.
• Assess for recent introduction of iodine-containing medications.
• Assess the patient for bradycardia,distended abdomen,dry thick cold skin,thick brittle nails,and muscular aches and pain.

2 The most common and reliable lab tests used to evaluate thyroid function are those that measures TSH and free T4. These values ,co related with symptoms gathered from the history and physical examination,confirm the diagnosis.Serum TSH help determine the cause of hypothyroidism.Serum TSH is high when defect is in the thyroid and low when it is in the pituitary or hypothalamus.An increase in TSH after TRH injection suggests hypothalamic dysfunction ,whereas no suggest anterior pituitary dysfunction.

3 Dose=Weight*dosage

weight=130 pounds

dosage=1.7mcg/kg,Convert mcg to mg,divide the mass value by 1000

0.0017mg

weight=130/2.205

=58.967kg

=59Kg

59Kg*0.0017=0.10mg

4

• Levothyroxine is the drug of choice to treat hypothyroidism.In the young and otherwise healthy patient,the maintenance replacement dose is adjusted according to the patient response and lab findings.
• In the older adult patient and the patient with compromised cardiac status ,a smaller initial dose is recommended because the usual dose may increase myocardial oxygen demand.
• The increased oxygen demand may cause angina and cardiac dysrhythmias.
• Individuals using levothyroxine should be cautioned by the health care team to have serum TSH checked 4 to 6 weeks after changing levothyroxine preparations.
• Liotrix may be used in acutely ill patients with hypothyroidism.

5 Patients with severe long standing hypothyroidism may display myxedema,the accumulation of hydrophilic mucopolysaccharides in the dermis and other tissues.This mucinous edema causes the characteristic facies of hypothyroidism.

Dietary modifications may be required in that certain foods act as goitrogens and can interfere with thyroid function and block absorption of thyroid medications.A key thing to remember with this patients is that they tend to be slow thinkers therefore they should be provided written instructions.Patient education includes nature and chronicity of the disease requiiring long term treatment.