What additional assessments should be included in the patient examination?

Discussion Peer/Participation Prompt [due Sunday at 11:59 pm]
Please respond to at least 2 of your peer’s posts. To ensure that your responses are substantive, use at least three of these prompts:
Respond to your fellow classmates postings as well and challenge each other to go beyond just the surface.
Take an alternate view to a peer and present a logical argument supporting a different perspective.
Share your thoughts on how you support their opinion and explain why.
Present new references that support your opinions.
Please be sure to validate your opinions and ideas with citations and references in APA format.
i will provide each peers post to respond on each treatment plan please use different updated reference for each.
peer#1Christie Sonchar
MondayFeb 7 at 12:02pm
Weight Gain and Fatigue
Scenario: A 42-year-old woman who is an established patient comes to an appointment complaining of sudden and unexpected weight gain, fatigue, and heavy menses for the past 3 months. The woman has a history of allergies, Guillain-Barre syndrome at age 18, depression, and some difficulty getting pregnant in the past. Her maternal grandmother had a history of thyroid problems, but no specific information was available.
What additional assessments should be included in the patient examination?
The subjective presentation of a patient experiencing hypothyroid can have a variety of symptoms depending on the severity of how bad/long the patient’s hypothyroid has been going on (Dunphy et al., 2019). Common early signs and symptoms can include dry skin, fatigue, slight weight gain, cold intolerance, constipation, past fertility issues, and current heavy menses (Dunphy et al., 2019). Therefore, in the above case, we know she has heavy menses, fatigue and weight gain so I would want to further assess for any symptoms of constipation, dry skin and cold intolerance. I would also want to ask this patient if they have had any muscle cramps, headaches, decreased libido, depression, trouble sleeping, or loss of hair (Ainsworth et al., 2021). If there is a presence of an enlarged thyroid gland, or goiter, asking this patient subjectively if they have had trouble swallowing or a change is their voice would be warranted (Ainsworth et al., 2021).
A thorough physical exam must be done to auscultate the patient’s heart, lung, and abdomen. In addition, inspection of the patient’s skin, head, extremities, abdomen and neurological wellbeing must be done (Dunphy et al., 2019). Objective assessments to include in this patient’s examination includes vital signs and comparing them to previous appointments would occur. They may present with bradycardia and depending on the severity of their hypothyroid their blood pressure could present as having mild diastolic hypertension (Demirel et al., 2017). Assessing their hair to see if it is course and thin and if there is a thinning of their lateral third of their eyebrows should be done (Ainsworth et al., 2021). Examining their mouth for any enlargement of their tongue by looking for scalloping on the edges where the teeth have pressed against the tongue must occur (McCance et al., 2019). Palpating the thyroid to determine its size must be done as should looking for any pitting edema of their lower extremities (McCance et al., 2019). Reflexes may be slow or delayed so these must be assessed as well (McCance et al., 2019). A cardiac assessment should also be done to see if the patient’s heart is enlarged (McCance et al., 2019). If there is a decrease in cardiac function, the patient may feel shortness of breath (McCance et al. 2019). Since this patient has a history of depression, utilizing a depression screening tool could be done. In addition, assuring that this patient has no suicidal thoughts must be accomplished.
Explain whether this patient should have had a routine screening of thyroid function.
Clinical guidelines do not recommend routine screening of women before age fifty years old if they do not have symptoms (Dunphy et al., 2019). Having said this, many providers begin to screen their patients after age forty and the American Thyroid Association recommends baseline screening at age thirty-five (Dunphy et al., 2019). Therefore, because this patient is forty-two and has had infertility issues in the past, has been depressed and has a family history of hypothyroidism as well as Guillain-Barre this patient should have had a routine screening of her thyroid function.
Which testing is needed to diagnose hypothyroidism?
Measuring serum thyroid stimulating hormone (TSH) which is produced from the anterior portion of the hypothalamus is used to diagnose hypothyroidism (Dunphy et al., 2019). Levels of free thyroxine (free T4) can also be used with the TSH as a low level of thyroxine and high level of TSH indicate an underactive thyroid (McCance et al., 2019). That’s because your pituitary produces more TSH in an effort to stimulate your thyroid gland into producing more thyroid hormone (McCance et al., 2019). It is important to note that ninety-percent of people who suffer from hypothyroid have Hashimoto’s, which is an autoimmune thyroid problem (McCance et al., 2019). Therefore, ordering antimicrosomal (anti-TPO) antibodies or antithyroglobulin antibodies may be done to assess for any autoimmune underlying root cause (McCance et al., 2019). Using TSH and free thyroxine (free T4) can help monitor hypothyroid treatment (Dunphy et al., 2019).
Why is the measurement of free T4 always preferred over the total T4?
The thyroid gland produces thyroxine (T4). Free T4 is that amount of thyroxine that is not bonded to protein in your blood, hence “free” (Brownstein, 2018). Free T4 is therefore available for use by your body and tissues as opposed to T4 that is bonded to protein. Total T4 measures the T4 that is bonded to protein along with any free T4 whereas a free T4 test measures only the free T4 that in in your blood (Brownstein 2018). Because free T4 is what is available for your body to use because it is not bound to protein, a free T4 test is often preferred over a total T4 test (Brownstein, 2018).
Under what circumstances should this patient be referred to an endocrinologist for treatment?
After therapy has began with levothyroxine, the TSH level should be monitored after four to eight weeks and adjust the medication dose accordingly (Dunphy et al., 2019). The TSH level should be between 0.3-2.4 mIU/L (Dunphy et al., 2019). If the patient has cardiac disease, symptoms of myxedema, or central (secondary or tertiary) hypothyroidism then a referral to an endocrinologist must be made (Dunphy et al., 2019). In addition, if the patient is not responding properly to the given therapy or treatment plan, an endocrinologist referral must occur (McCance et al., 2019). Since this patient has the potential to become pregnant, an endocrinologist referral can be made if this occurs or if during the exam thyroid nodules or difficulty swallowing is present.
References
Ainsworth, A., Alaa, N., Bernett, V. (2021). Hypothyroidism. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypothyroidism/symptoms-causes/syc-20350284
Brownstein, D. (2018). Thyroid function tests. American Thyroid Association. https://www.thyroid.org/wp-content/uploads/patients/brochures/FunctionTests_brochure.pdf
Demirel, M., Gürsoy, G., & Yıldız, M. (2017). Does treatment of either hypothyroidy or hyperthyroidy affect diurnal blood pressure. Archives of Iranian Medicine, 20(9) https://prx-herzing.lirn.net/login?url=https://www.proquest.com/scholarly-journals/does-treatment-either-hypothyroidy-hyperthyroidy/docview/2086249807/se-2?accountid=167104
Dunphy, L. E., Winland-Brown, J. E., Porter, B.O., & Thomas, D. J. (2019). Glandular disorders. Primary Care: The Art And Science Of Advanced Practice Nursing-An Interprofessional Approach (pp. 890–898). F.A. Davis.
McCance, K. L., & Huether, S. E. (2019). Alterations of hormonal regulation. Pathophysiology: The Biologic Basis For Disease In Adults And Children (pp. 679-682). Elsevier.
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peer#2
Dawn Stevens
TuesdayFeb 8 at 7:06pm
Scenario: A 42-year-old woman who is an established patient comes to an appointment complaining of sudden and unexpected weight gain, fatigue, and heavy menses for the past 3 months. The woman has a history of allergies, Guillain-Barré syndrome at age 18, depression, and some difficulty getting pregnant in the past. Her maternal grandmother had a history of thyroid problems, but no specific information was available.
What additional subjective and objective assessments should be included in the patient examination?
A complete review of systems is needed because symptoms are often subtle and may involve every bodily system (Dunphy et al., 2019). Review of systems would need to specifically include skin to assess for reports of dry skin, coarse hair, alopecia, and/or loss of lateral eyebrows. It would also include musculoskeletal to assess for reports of muscle cramps, myalgia and weakness. I would also ask about possible cold intolerance, constipation, history of headaches, trouble sleeping and any changes in libido. A more detailed gynecologic history is needed to assess characteristics, possible irregularity and duration of menstrual periods. Specifically for Hashimotos’, I would ask about sore throat, neck pain and hoarseness.
Objective assessment would include assessing thinning and texture of the hair and eyebrows as well as thickened tongue. The thyroid would obviously need to be assessed to check for enlargement, tenderness and possible goiter. It is important to note size, nodularity and any scars to signify any previous thyroid surgery. Measurement and comparison to previous vitals and weight needs to be included. It is important to note specifically the heart rate as bradycardia can be present along with a pericardia effusion. Hypothyroidism can result in increased vascular resistance, decreased left ventricular function and other cardiac changes so it is important to note the point of maximal impulse as it can be displaced as a result (Chaker et al., 2017). Abdominal assessment to note possible diminished or hypoactive bowel sounds. Neurological exam is important to note any ataxia or hypotonic reflexes.
Explain whether this patient should have had a routine screening of thyroid function prior to today’s visit.
Yes, this patient should have had her thyroid function monitored routinely prior to today’s visit. Her age, gender and the fact that she lives in the United States places her in a high risk category. The incidence of hypothyroidism is 2 to 8 times greater than in men (Dunphy et al., 2019). Middle age females including ages 30-50 years old are at peak incidence for autoimmune thyroiditis (Chaker et al., 2017). The patient having depression is another clue to check for hypothyroidism as the signs and symptoms are similar. There is also a correlation between lower TSH and the incidence and severity of Guillain-Barré syndrome (Huang et al., 2017).
Which testing is needed to diagnose hypothyroidism?
Primary hypothyroidism is defined by TSH concentrations above the reference range and free thyroxine concentrations below the reference range.(Chaker et al., 2017). The measurement of thyroid peroxidase antibody is not necessary to diagnose hypothyroidism but is useful to confirm autoimmune primary hypothyroidism (Chaker et al., 2017). Once a diagnosis of hypothyroidism is confirmed, additional testing may be necessary to determine the effect of the disease on other bodily systems (Dunphy et al., 2019).
Why is the measurement of free T4 always preferred over the total T4?
Measurement of FT4 is always preferred over total T4, because of alterations in the protein-binding of thyroid hormone levels that can result in large fluctuations in total serum T4 levels (Dunphy et al., 2019).
Under what circumstances should this patient be referred to an endocrinologist for treatment?
A referral to an endocrinologist is necessary if the patient has cardiac disease, symptoms of myxedema, or central (secondary or tertiary) hypothyroidism (Dunphy et al., 2019). Hypothyroid patients who are severely ill, on hormone replacement therapy, or with unusual labs need to be referred to an endocrinologist. Referral to an endocrinologist is also indicated in patients younger than 18 years of age, in those with evidence of pituitary disease, in pregnant and postpartum patients, and in patients taking lithium or amiodarone (Dunphy et al., 2019).
References
Chaker, L., Bianco, A. C., Jonklaas, J., & Peeters, R. P. (2017). Hypothyroidism. The Lancet, 390(10101), 1550–1562. https://doi.org/10.1016/s0140-6736(17)30703-1 (Links to an external site.)
Dunphy, L. E., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2019). Primary care: the art and science of advanced practice nursing-an interprofessional approach (5th ed.). F.A. Davis.
Huang, Y., Ying, Z., Chen, Z., Xiang, W., Su, Z., Quan, W., Weng, Y., & Zhang, X. (2017). Thyroid hormone level is associated with the frequency and severity of guillain–barré syndrome. International Journal of Neuroscience, 127(10), 893–899. https://doi.org/10.1080/00207454.2016.1278541 (Links to an external site.)
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