Case Study: Maria Ash - Investigating Fatigue and Weight Gain, Exams of Nursing

Download Case Study: Maria Ash - Investigating Fatigue and Weight Gain and more Exams Nursing in PDF only on Docsity! 1 Maria Ash Ihuman Case Study Reason for Fatigue and Weight Gain Unit 5 Ihuman Maria Ash CC: Fatigue and weight gain Questions Onset: when did the fatigue start? Location: Duration: does this last all day or even after a good night of rest? Characteristics: Aggravating/Relieving: does anything make the fatigue better or worse? Treatment: Have you tried anything to help? When did you first notice the weight gain? How much weight have you gained? Have you tried anything to lose weight? Have you always felt cold when other were warm? Did you just start to notice decreased energy? Do you have pain or swelling in your neck? Radiation to the neck? Previous endocrine problems? Dietary questions (?) Classic early symptoms include fatigue, dry skin, slight weight gain, cold intolerance, constipation, and heavy menses Myalgia, muscle cramps, headaches, and weakness may also be present Later symptoms: very dry skin, coarse hair, loss of lateral eyebrows, alopecia, hoarseness, weight gain, slight impairment in mental ability, depression, decreased libido, and hypersomnia Women require a full menstrual history including date of most recent period, characteristics, and duration More specific to Hashimoto’s-painless thyroid enlargement, neck pain, sore throat, a feeling of fullness in the throat, low grade fever, and exhaustion Mild diastolic hypertension Family history- ask about thyroid problems History of thyroid surgery or radiation in your neck to treat cancer Are you currently on any medication (amiodarone, lithium, interferon alpha, iodine,interleukin-2 or prior chemotherapy can cause these issues) 2 SOAP NoteMariah AshMariah Ash - 41 year old woman with 65kg complaining of weight gain and fatigue. 1) How can I help you today?- fatigue, it’s getting harder and harder to get through a normalwork today 2) Do you have any other symptoms or concerns we should discus? – Gaining weight, but I swear I am watching what I eat. Bowel habits, I seem to have some constipation Fatigue-onset, • When did your fatigue/tiredness start? • Do you become more weak or tired with exertion? – Yes, I got tired doing household tasks like gardening. I feel some days I need to take an afternoon nap. I try to keep going through anyway • How severe is your fatigue/tiredness?- I guess I’m mostly funcining, but It’s concerning enough that I came in to find out why and ge to the bottom • Have you had fatigue/tiredness problems like this before? • Has there been any change in your fatigue/tiredness over time?•Not much, maybe a bit worse lately • Does your fatigue/tiredness improve after a good night’s rest? – Some, but not back to normal • Is your fatigue unrelated to physical effort?- I don’t have my normal energy when I wake up, but Ifeel really tired at the end of the day. This is not normal for me. I usually feel energized after teaching classes. I’m the oldest fitness trainer at the gym. • Weight gain- When did your problem with weight gain start?- Not sure, I gained most of my weight during the last 3-4 months • Constipation- Do you have any pain or other symptoms associated with your constipation? 0 No pain•- Have you had constipation problems like this before? No, never•-Is there any change in the shape of your stools?- smaller, more compact•When did your problem with constipation start? –Not sure, at least last 4-6 weeks • Are you taking any over-the-counter or herbal emdications? –Not really, just vitamins and calcium, tried fiber supplement for 2 or 3 days•Any diet changes since your last appointment? SOAP NoteMariah AshName: Maria AshAge: 41 yearsSex: FCC:Maria reports to office today with a c/o fatigue, weakness, constipation, temperature intolerance, and unintentional weight gain of 15lbs (6.8kg) over the past 3 months. DDX:Hypothyroidism, Chronic Fatigue Syndrome, Anemia, Depression Patient reports worsening fatigue for about 3 months, and notices unintentional weight gain of 15 pounds. Patient also has constipation, menstrual pried lengthening with irregular menses, dry facial skin. Patient also has elevated diastolicBP (narrowed pulse pressure). She has bradycardia, and has slightly enlarged thyroid (35gm) and hypoactive bowel sounds. HPI:She reports the fatigue and weakness x 3 months are interfering with herwork performance and ADLs. She reports sleeping well but fatigued by Expert's Feedback 1. atypical depression This differential diagnosis should be included because: Atypical depression is a subtype of major depression or dysthymic disorder that involves several specific symptoms, including increased appetite or weight gain, sleepiness or excessive sleep, marked fatigue or weakness, moods that are strongly reactive to environmental circumstances, and feeling extremely sensitive to rejection. Symptoms of depression can vary from person to person. Key signs and symptoms may include the following: e Depression that temporarily lifts in response to good news or positive events @ Increased appetite that can cause weight gain ¢ Increased desire to sleep, usually more than 10 hours a day ° Heavy, leaden feeling in your arms or legs that lasts an hour or more in a day — a feeling that is different from fatigue ° Sensitivity to rejection or criticism, which affects your relationships, social life or job Other symptoms also may be part of atypical depression, such as: @ Insomnia « Disordered eating, such as bulimia, bingeing or extreme food restrictions @ Poor body image and fear of being fat ° Headaches and other aches and pains ~  Risk factors: Many factors seem to increase the risk of developing or triggering depression, whether it's atypical or not. Risk factors may include: oo 00 0 o 8 oo 6 0 oo History of bipolar disorder Abuse of alcohol ar recreational drugs Physical or sexual abuse Traumatic childhood experiences Certain personality traits, such as low self-esteem or being overly dependent Serious illness, such as cancer or heart disease Certain medications, such as some high blood pressure medications or sleeping pills (talk to your doctor before stopping any medication) Environmental stressors Blood relatives with a history of depression, bipolar disorder or alcoholism Stressful life events, such as the death of a loved one Depression after giving birth (postpartum depression) Family members who committed suicide Few friends or other personal relationships  Discussion: Hypothyroidism is the leading hypothesis in this female because it is a unifying diagnosis. that can explain all of her clinical findings. Low thyroid hormone level results in a generalized feeling of fatigue made worse with exertion. The unintentional weight gain while possibly eating less is also explained because of lower basal metabolic rate as is the dry skin and constipation. In addition, menometrorrhagia and lengthening of the menstrual periods can occur with low thyroid levels. The other diagnoses are also possibilities, but are alternative either because they are less frequent or because one might need two different diagnoses to fully explain all of her complaints/findings. While we look for a single unifying diagnoses, one must remember that it is possible to have two things occur in close time proximity and thus. look like a single event. Atypical depression (possibly due to her daughter going away to college) could explain fatigue and depression and frequently results in eating poorly, maybe something she is less aware of. Both dry facial skin and constipation are problems that are associated with aging. Finally, her increased menstrual flow and changes in length could be signs of the start of menopause. This is an 8-10 year process and frequently starts at the same age as ones’ mother. Another possibility is chronic fatigue syndrome either alone or possibly combined with a mild anemia from the heavy menstrual flow. Chronic fatigue syndrome is a complicated disorder that cannot be explained by other medical conditions. This sounds like what our patient is describing. The cause remains unknown, but the symptoms are worsened with exertion, similar to what our patient relates to us. Review your list of key findings carefully. Order those tests that will facilitate identifying the true cause of this patient's fatigue Expert's Feedback Hypothyroidism is the definitive diagnosis secondary to Hashimoto's disease. Maria's FT4 level is below normal, driving her pituitary to produce increased levels of TSH (thyroid stimulating hormone) in an attempt to increase thyroid hormone levels. The elevated TPO antibody and lack of thyroid pain, suggests an autoimmune process of thyroid tissue destruction. This would explain the following presentation: * gradual onset of fatigue * gradual weight gain and easy fatigability « dry facial skin * constipation * menstrual change with menorrhagia Please review the following: Hashimoto Thyroiditis  Case Summary eB | Learning objectives After completing this case, the student should be able to do the following + Leam history taking, general and systemic examination Recognize symptoms and elicit signs of hypothyroidism * Understand hypothyroidism management + Describe pathophysiology of hypothyroidism, its various etiologies, and epidemiology pidemiology Worldwide, the most common cause of hypothyroidism is iodine deficiency. However, Hashimoto thyroiditis remains the most common cause of spontaneous hypothyroidism in areas of adequate iodine intake such as the USA. The annual incidence of Hashimoto thyroiditis worldwide is estimated to be 0.3-1.5 cases per 1000 persons. The incidence of Hashimoto thyroiditis is estimated to be 10-15 times higher in females, The most commonly affected age range in Hashimoto thyroiditis is 30-50 years. The overall incidence of hypothyroidism increases with age in both men and women. The mean annual incidence rate of autoimmune hypothyroidism is 4 per 1000 women and 1 per 1000 men, thus also showing a gender preference {tis more common in certain populations, such as the Japanese, probably because of genetic factors and possibly due to chronic exposure to a high-iodine diet + The mean age at diagnosis is 60 years, and the prevalence of overt hypothyroidism increases with age Subclinical hypothyroidism is found in 68% of women (10% over the age of 60) and 3% of men The annual risk of developing clinical hypothyroidism is about 4% when subclinical hypothyroidism is associated with positive TPO antibodies. _ Risk Factors + Genetic Susceptibility: There is significant familial predisposition to autoimmune disease in patient with autoimmune thyroid disease but weak association between Hashimoto's disease and HLA-DR3, HLA-DRS, and certain DQ alleles. I's linkage to specific histocompatibility antigen is difficult to demonstrate like diabetes. In Down syndrome, Hashimoto's disease occurs frequently. Thyroid cell can express HLA antigen so it has a potential role in causing the immune response that may be disposed as autoimmune disease for some HLA-DR subgroups. Hashimoto's disease is assuredly associated with polygenetic susceptibility, HLA may be the one gene involved, non HLA susceptibility gene with autoimmune thyroid disease association may be present In this way, Polymorphism in the CTLA4 gene related to secrete thyroid autoantibody so it may be an important risk factor for disease itself. | Non-genetic Risk Factors | Factors like pregnancy, drugs, age and sex, infection, and irradiation also increases the risk of autoimmune thyroiditis. Pregnancy: Pregnancy is an important risk factor. Some patients develops transient postpartum thyroiditis and in some thyroid failure develops permanently or in the early years after pregnancy. lodine and Drugs: lodine and iodine-containing drugs (such as amiodarone) precipitate autoimmune thyroiditis in susceptible populations. This form should be distinguished from direct blockade and destruction of the thyroid gland by iodine. The mechanism of this precipitation is unknown Cytokines: Treatment of patients with interleukin-2 or interferon-a may precipitate the appearance of autoimmune thyroid disease. Autoimmune thyroid disease is more common in patients with pre-existing TPOAbs. Irradiation: Radiation exposure induces thyroid autoantibodies and autoimmune thyroid disease Age: Autoimmune thyroid failure continues to occur throughout adult life, so that the prevalence of the disease increases markedly with age. This is similar to other markers of autoimmunity and may reflect an increasing loss of tolerance to self. Infection: Infection may be a likely cause of a local or distant insult in autoimmune disease to precipitate it in susceptible individuals Smoking: Smoking significantly increases risk for thyroid disease, particularly autoimmune Hashimoto's thyroiditis and postpartum thyroiditis. Smoking also increases the negative effects of hypothyroidism, notably on the arteries and heart | Clinical considerations and pearls | Common symptoms and sign suggestive of hypothyroidism in descending order of frequency are listed in the table below. Please note that | many of these are seen only in situations of prolonged and extreme hypothyroidism  Symptoms Tiredness, weakness Dry skin Feeling cold Hair loss Difficulty concentrating and poor memory Weight gain with poor appetite Constipation Dyspnea Hoarse voice Menorthagia (later oligomenorthea or amenorrhea) Signs Dry coarse skin; cool peripheral extremities Puffy face, hand and feet (myxedema) Diffuse alopecia Bradycardia Peripheral edema Carpal tunnel syndrome Delayed tendon reflex relaxation Serous cavity effusion Paresthesia Impaired hearing CAUSES OF HYPOTHYROIDISM + Primary Hypothyroidism © Acquired Hashimoto's thyroiditis © Congenital TSH receptor” defects lodine deficiency (endemic goiter) Drugs blocking synthesis or release of TA (e.,, lithium, ethionamide, sulfonamides, iodide) Goitrogens in foodstuffs or as endemic substances or pollutants Cytokines (interferon-a, interleukin-2) Thyroid infitration (amyloidosis, hemochromatosis, sarcoidosis, Riedel's struma, cystinosis, scleroderma) Postablative due to 1311, surgery, or therapeutic irradiation for nonthyroidal malignancy lodide transport or utilization defect (NIS or pendrin mutations) lodotyrosine dehalogenase deficiency Organification disorders (TPO" deficiency or dysfunction) Defects in thyroglobulin synthesis or processing Thyroid agenesis or dysplasia Thyroidal Gs protein abnormalities (pseudohypoparathyroidism type 1a) Idiopathic TSH unresponsiveness + Transient (Post thyroiditis) Hypothyroidism © Following subacute, painless, or postpartum thyroiditis + Consumptive Hypothyroidism © Rapid destruction of thyroid hormone due to D3 expression in large hemangiomas or hemangioendotheliomas * Defects of Thyroxine to Triiodothyronine Conversion © Selenocysteine insertion sequence-binding protein (SECIS-BP2) defect «Drug-induced Thyroid Destruction © Tyrosine kinase inhibitor (sunitinib)  * Central Hypothyroidism 2 Acquired = Pituitary origin (secondary) = Hypothalamic disorders (tertiary) = Bexarotene (retinaid X receptor agonist) = Dopamine and/or severe illness © Congenital «TSH deficiency or structural abnormality = TSH receptor defect © Resistance to Thyroid Hormone = Generalized = “Pituitary” dominant Basic-science considerations | Hashimoto thyroiditis is progressive thyroid failure due to autoimmune disease, which causes impairment of hormone synthesis or | hypothyroidism .At least 90% of the thyroid gland must destroy before developing hypothyroidism. In autoimmune thyroiditis or Hashimoto's disease formation of circulating autoantibodies against thyroglobulin and thyroperoxidase occur. This is possibly because of abnormalities of regulatory T cells or due to exposure of normally sequestrated thyroid antigens. This is a mechanism of | breakdown of peripheral tolerance to thyroid antigen. | There may be multiple mechanisms which contribute to thyroid cell death including- | CD8+ cytotoxic T cell mediated cell death —it may be Fas ligand associated or another pathway may involve. | Cytokine-mediated cell death- as interferon gamma which recruits macrophages and damages the follicle | Binding of antithyroid antibodies (antithyroglobulin and antithyroid peroxidase antibodies) | This express that Hashimoto thyroiditis has a strong genetic association | | Patient Disposition Maria started her thyroid hormone replacement. She obtained new lab values 5 weeks later. She felt markedly better (took about 3 weeks) but | she has also lost about 2 bs over the last 5 weeks without even trying, Her FT4 is just barely in the normal range and her TSH remains | slightly elevated. The decision was made to continue on the same dose as she expected she would be losing her gained weight over time and | thus would rather get to her normal weight before making any medication final adjustments. | Her last menstrual period was heavy, but she was assured that this would take 2-3 cycles before returning to normal. She is scheduled for a | follow-up clinical visit with labs ahead of time in 3 months.