complaint of weight gain and fatigue

• A 43-y.o. female presents with the complaint of weight gain and fatigue over the past 4 mo. She states that she is always cold and just can’t get warm. She states that she is sleeping really well through the night but does not wake feeling refreshed. She denies shortness of breath, chest pain, or dyspnea on exertion.
  1. You are the provider,What additional questions should you ask the patient and why?
  2. What should be included in the physical examination at this visit?
  3. What are the possible differential diagnoses at this time?
  4. What tests should you order and why?
  5. How should this patient be managed?

Students are expected to:

1. Post an initial substantive response(min250) of to each questions as an FNP. Use Diagnostic Reasoning to answer each question.
2. Please be sure to validate your opinions and ideas with in text citations and references in APA format.
3. References and citations should conform to the APA 6th edition.
4. Substantive comments add to the discussion and provide your fellow students with information that will enhance the learning environment.
5. The peer postings should be at least one paragraph (approximately100 words)

Timothy’s Response:

A 43-y.o. Female presents with the complaint of weight gain and fatigue over the past four months. She states that she is always cold and just can’t get warm. She states that she is sleeping really well through the night but does not wake feeling refreshed. She denies shortness of breath, chest pain, or dyspnea on exertion.

Based on the patient’s complaint of weight gain and fatigue and the ability of not being able to get warm, the patient should be screened for thyroid disease. According to Dunn and Turner (2016), thyroid disease is a major health issue in the United States. Approximately 20 million Americans have been diagnosed or are being treated for thyroid disease. Hypothyroidism is the second most common type of endocrine disorder affecting women of reproductive age, but it can affect women across the lifespan. The thyroid maintains metabolism and vital body functions. It is located in the anterior neck just below the larynx and is composed of two lobes that straddle the trachea. Hypothyroidism occurs when the thyroid gland does not make enough thyroid hormone. According to Ross (2017), thyroid hormone normally stimulates the metabolism, and most of the symptoms of hypothyroidism reflect the slowing of metabolic processes. General symptoms may include fatigue, sluggishness, slight weight gain, and intolerance of cold temperatures.

What additional questions should you ask the patient and why?

There should be some questions related to social histories such as smoking, alcohol consumption, illicit drugs, and living conditions. The patient should also have questions related to relationship status, sexual history, support system, and occupation status. Several other questions could be related to diet, exercise, caffeine consumption, and current medications. Allergies to medications, health maintenance questions related to pap smears and last annual health exams, and any family history related to thyroid disorders should be asked to help gather information related to the symptoms the patient has. The patient should also give a history of any past surgical interventions that were done in the past.

These questions can help to discover any changes in bowel habits since hypothyroidism can cause constipation. They can also answer questions related to changes in eating habits since hypothyroidism can cause slight weight gain despite no changes in eating habits. The consumption of iodized salt is important since the most common worldwide cause of thyroid disorders is iodine deficiency. The patient could find that there might be some changes in mood or depression since mild depression and lethargy are common symptoms of hypothyroidism. The questions could reveal that the patient has had a change in their libido over the past several months since decreased libido is a common complaint associated with hypothyroidism. Medications, such as lithium and amiodarone, can cause thyroid failure. These are just a few questions that could help with the history of the patient.

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

The overall appearance of the patient associated with movements and reactions to questions being asked. The blood pressure, resting pulse, respiratory rate, and weight should be compared to past visits. The appearance of the patient’s hair, eyebrows, and nails should be noticed during the exam. Evaluate the patient’s neck to check for scars, swelling, or tenderness and to make sure no goiter is present. The lungs should be clear in all fields during auscultation. The abdomen should be soft and non-tender with bowel sounds in all quadrants with auscultation. The patient should have all reflexes checked during the exam as well as all lymph nodes.

What are the possible differential diagnoses at this time?

According to Dunn and Turner (2016), the possible differential diagnoses at this time would be thyroiditis, neoplasm (thyroid CA), anemia, peripheral vascular disease, and depression.

What tests should you order and why?

According to Dunn and Turner (2016), hypothyroidism can be confirmed with laboratory evaluation of TSH and T4 levels. The primary screening test to evaluate thyroid function measures TSH level because, if T3 and T4 levels are low, the pituitary gland produces more TSH. If the TSH level is elevated, the next step is to measure free T4 or the free T4 index. A CBC should be ordered to help rule out any underlying anemia. An EKG should be performed for baseline assessment for bradycardia, if the patient has any cardiac history and if the patient starts to have new cardiac symptoms. A pregnancy test should be performed to determine dosage due to pregnancy increases the protein binding. A CMP and Lipid panel should be performed to help monitor electrolytes and lipids during treatment.

How should this patient be managed?

According to Ross (2017), Women with primary hypothyroidism should be treated. The goal of treatment for hypothyroidism is to return blood levels of thyroid-stimulating hormone (TSH) and thyroxine (T4) to the normal range and to alleviate symptoms. The treatment for hypothyroidism is thyroid hormone replacement therapy. This is usually given as an oral form of T4 (levothyroxine). T4 should be taken once per day on an empty stomach (ideally one hour before eating or two hours after; most patients take their hormone as soon as they wake in the morning, and delay eating breakfast as long as practical before leaving for work or school). Generic (levothyroxine) and brand-name (Synthroid, Levoxyl, Levothroid, Unithyroid, Tirosint) formulations are equally effective. However, it is preferable to stay on the same manufacturer of T4 rather than switching between brand name and/or generic formulations.

Additionally, women with subclinical hypothyroidism with a TSH level greater than 10 mIU/L should be treated. Treatment of women with a TSH level less than 10 mIU/L should be done on a case-by-case basis. According to Dunn and Turner (2016), women whose symptoms have resolved and who have a therapeutic TSH level on the prescribed dosage of levothyroxine should undergo TSH level evaluation at least every 12 months. The TSH levels should also be re-evaluated 4 to 8 weeks after initiation or alteration of the dosage of levothyroxine. According to Dunn and Turner (2016), Women with hypothyroidism should be referred to an endocrinologist for the following: difficulty maintaining a euthyroid state, during pregnancy, when planning to become pregnant, cardiac disease, presence of a nodule or other abnormal thyroid structural changes, presence of other endocrine abnormalities such as pituitary and adrenal disorders, and unusual causes of hypothyroidism related to malabsorption of levothyroxine.

References

Dunn, D., & Turner, C. (2016). Hypothyroidism in Women. Nursing for Women’s Health (NWH), 20(1), 93-98. http://dx.doi.org/10.1016/j.nwh.2015.12.002

Ross, D. S. (2017). Patient education: Hypothyroidism (underactive thyroid) (Beyond the Basics). UpToDate. Retrieved from https://www.uptodate.com/contents/hypothyroidism-u…

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Jason’s Response:

What additional questions should you ask the patient and why?

The patient presented has symptoms consistent with an endocrine disorder. Therefore, questions should be initiated

based on differential diagnoses to support ruling in/out this etiology. Subjective symptoms of hypothyroidism include fatigue,

cold intolerance, weight gain, myalgias, dry skin, alopecia, headaches, constipation, depression, hypersomnia, decreased

libido, hoarseness, and decrease in mental sharpness (Dunphy, Winland-Brown, Porter, & Thomas, 2015). A complete history

is important because there are numerous causes of hypothyroidism including iodine deficiency, medications, genetic thyroid

enzyme defects, thyroid surgery, and Hashimoto’s thyroiditis (sore throat/fullness in the throat/ neck pain) (Goolsby &

Grubbs, 2011).

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

According to Dunphy, Winland-Brown, Porter, & Thomas (2015), “The physical exam should begin with observation of the

overall appearance of the patient, noting slow movements and dull facies. The blood pressure, resting pulse, respiratory rate,

and weight should be compared with previous exams (p. 859). A focused exam of the thyroid gland noting any nodules or

goiter is recommended and the reflexes should be noted on neurologic exam. Delayed DTR’s and hypotonicity are a common

assessment finding in patients with hypothyroidism (Goolsby & Grubbs, 2011). Other physical exam findings indicative of

hypothyroidism are bradycardia, periorbital edema, brittle nails, and enlarged tongue (Ross, 2017).

What are the possible differential diagnoses at this time?

There are multiple differentials to consider regarding this patient including, but not limited to anemia, obstructive sleep

apnea, adrenal insufficiency, vitamin D deficiency, and Lyme disease (Chaker, Bianco, Jonklaas, & Peeters, 2017).

What tests should you order and why?

Baseline lab testing should include a complete blood count and chemistry to rule out anemia and other overt metabolic

conditions. Thyroid stimulating hormone (TSH) is warranted because the diagnosis of thyroid disease is primarily formed

based on lab testing (Ross, 2017). An elevated TSH warrants repeat testing of the TSH in addition to T4. If the TSH is elevated

above reference and the T4 is low, this is considered a positive diagnostic test for primary hypothyroidism (Chaker et al.,

2017).

How should this patient be managed?

Levothyroxine, taken on an empty stomach, is the treatment of choice for primary hypothyroidism (Chaker et al., 2017).

Normal dosing for levothyroxine is 50-100 mcg orally daily (Dunphy et al., 2015). The TSH should be repeated in 4-12 weeks

and adjustments in dosing made accordingly with the knowledge that over treatment can have negative outcomes just as

under treatment (Chaker et al., 2017).

References

Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017, September 23). Hypothyroidism. Lancet, 390, 1550-1560.

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 ]. Retrieved from https://bookshelf.vitalsource.com/#/books/97803234…

Goolsby, M., & Grubbs, L. (2011). Advanced assessment: Interpreting findings and formulating differential diagoses (2nd ed.).

Philadelphia, PA: F.A. Davis Company.

Ross, D. S. (2017). Diagnosis and screening. In D. S. Cooper (Ed.), Diagnosis of and screening for hypothyroidism in nonpregnant

adults. Retrieved from https://www.uptodate.com/