Case Study Martha Krauntz – The final diagnosis is hypothyroid. The patient presents cold symptoms, including copious, clear to yellow nasal discharge, sneezing, head stuffiness, occasional mild headache, and mild cough….
NSG 5540 CASE STUDY TEMPLATE
Title page – including the identified case study name and number
Learning Issues?– what do you need more information in order to develop a plan? If so, what information do you need or want? (Can be bullet points)
- Example – Chest Pain
- How do you evaluate a patient with a history of chest discomfort and risk factors for heart disease?
- What are the laboratory findings that are important to look for with someone with chest discomfort?
- How do you manage abnormal lipids?
- What lifestyle changes are important to recommend to reduce cardiac risk
Interpretation of Cues, Patterns, and Information?– symptoms analysis and identification of any missing data that would helpful in making a plan for care (Can be bullet points)
- Example – Chest pain
- Chest discomfort – musculoskeletal vs gastrointestinal vs cardiac vs respiratory?
- What labs are missing that would assist in the planning process for this patient?
- Family history that could increase risk of cardiovascular disease
- Psychosocial issues – caffeine intake, smoking, ETOH use, or working history
Differential Diagnoses?– include 3 differential diagnoses including ICD-10 codes (Can be bullet points)
- Example – Chest pain RO7.9
Precordial Pain – R07.2
Acute Myocardial Infarction – I21.9
Gastroesophageal Reflux Disease without esophagitis– K21.9
Diagnostic Options?– what additional laboratory work, diagnostic testing, or possible referrals may be required? (Can be bullet points)
Final Diagnosis?- what is the most probable cause of the patient problem?
Therapeutic Options?– this is related to your final diagnosis (Paragraph Form or Bullet Points)
- Social Determinants of Health
Follow up?– when should this patient return to the office? What conditions would need earlier follow up? (Paragraph Form)
Respond to at least 2 peers with meaningful responses and respond to faculty-you may constructively critique peer cases, use rationales and citations
References page?(APA Format). Do not use references greater than 5 yrs old.
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Case Study Martha Krauntz
- The reasons behind her ears hurting without a cold in her previous flight.
- Does Vitamin C and Echinacea relieve cold?
- If so, how much should be prescribed?
- Laboratory results of the cold symptoms.
- Additional ear tests following previous pain during her flight.
Interpretation of Cues, Patterns, and Information
- The patient has a family history of hypothyroidism, increasing her chances of getting cold symptoms (Wassner, 2020).
- The patient is female, which increases her risk for hypothyroidism. According to Chiovato et al. (2019), women are ten times more likely to have thyroid disorders than men. One reason behind this is that autoimmune responses are triggered, especially among females.
- The patient has had two previous hospitalization due to uncomplicated childbirth and has erratic and light periods, which could be symptoms of hypothyroidism.
- The patient uses IUD as a birth control method which may affect the thyroid. According to Ettleson and Bianco (2020), being on birth control methods, the progesterone and estrogen inside the IUD or pills can affect the thyroid binding proteins by increasing them.
- The patient has normal vital signs, including temperature, respiration, pulse oximetry, and pulse.
- Hypothyroidism E03.9
- Sinus Infection J01.90
- Rhinorrhea J34.89
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- Conduct a thyroid-stimulating hormone (TSH) test, a blood test to diagnose hypothyroidism. Conducting a blood test will help determine if the patient’s thyroid glands are functioning appropriately by measuring the amount of thyroid hormones in the blood.
- Specifically, the TSH test will help assess any thyroid hormone deficiency. If the TSH levels are abnormal, thyroxine (T3) and triiodothyronine (T4) tests are required to evaluate the exact problem. According to Chiovato et al. (2019), an adult’s normal thyroid hormone test range should be 0.4-0.5 mlU/mL. Nonetheless, the normal range for T3 thyroxine should be 5.0-11.0 ug/dL, while T4 levels should be 100-200 ng/dl (Ettleson & Bianco, 2020).
- Conduct additional blood tests, including;
- Thyroid antibodies- these tests can help identify the different types of autoimmune thyroid conditions. Specifically, conduct microsomal antibodies, thyroglobulin antibodies, and thyroid receptor antibodies tests (Ettleson & Bianco, 2020).
- Calcitonin- This blood test helps to diagnose C-cell hyperplasia.
- Thyroglobulin- This blood test helps to diagnose any thyroid inflammation.
- Conduct an ear test using a pneumatic otoscope to diagnose an ear infection.
- Conduct a physical examination for acute sinusitis by assessing the symptoms presented by the patient. This may also include checking for face and nose tenderness.
- Other tests may include;
- CT scan of the nasal areas to check for abnormalities or suspected complications.
- Lab test on nasal and sinus samples to assess for any infection.
- Nasal endoscopy, where an endoscope is inserted with a fiber-optic light through the nose to allow visual inspection of sinuses.
(Kim et al., 2019).
The final diagnosis is hypothyroid. The patient presents cold symptoms, including copious, clear to yellow nasal discharge, sneezing, head stuffiness, occasional mild headache, and mild cough. Additionally, she is on IUD and experiences irregular periods. Although she denies having ear pain, dental pain, or fever, she has a medical history of ear pain with no cold in her last flight. These symptoms indicate that the patient has an autoimmune response that makes her immune weaker to bear a cold. The patient’s mother has also been diagnosed with the condition, making her prone to having it. I have ruled out sinuses and rhinorrhea because the patient does not present fever, congestion, or pressure around the nose and nosebleeds.
- Administer levothyroxine or Synthroid orally to restore hormone levels.
- Administer vitamin B-12 supplements to repair the damages caused by hypothyroidism.
- Educate the patient on the causes and effects of hypothyroidism.
- Discuss the need to adhere to treatment.
- Instruct the patient on the dosage for self-medication.
Social Determinants of Health
- Eat healthy diets that include vegetables, fruits, lean proteins, healthy fats, and whole grains.
- Exercise Regularly
(Chiovato et al., 2019).
The patient should return to the clinic six weeks after the initial treatment to check thyroid levels and change treatment when needed. However, if the symptoms persist, the patient can revisit sooner.
Chiovato, L., Magri, F., & Carlé, A. (2019). Hypothyroidism in context: Where we have been and where we’re going. Advances in Therapy, 36(S2), 47-58. https://doi.org/10.1007/s12325-019-01080-8
Ettleson, M. D., & Bianco, A. C. (2020). Individualized therapy for hypothyroidism: Is T4 enough for everyone? The Journal of Clinical Endocrinology & Metabolism, 105(9), e3090-e3104. https://doi.org/10.1210/clinem/dgaa430
Kim, Y., Lee, K. J., Sunwoo, L., Choi, D., Nam, C., Cho, J., Kim, J., Bae, Y. J., Yoo, R., Choi, B. S., Jung, C., & Kim, J. H. (2019). Deep learning in the diagnosis of maxillary sinusitis using conventional radiography. Investigative Radiology, 54(1), 7-15. https://doi.org/10.1097/rli.0000000000000503
Wassner, A. J. (2020). Unraveling the genetics of congenital hypothyroidism: Challenges and opportunities. The Journal of Clinical Endocrinology & Metabolism, 105(9), e3464-e3465. https://doi.org/10.1210/clinem/dgaa454
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