Question

NUR 303 - Nursing Pathophysiology

Unit X Case Study: Hyperthyroid Disease

Patient’s Chief Complaints:

“I was jogging in the park like I do most mornings. Suddenly, I couldn’t catch my breath and I felt very dizzy. When I sat down on a park bench for a minute, I noticed a weird feeling in my chest—like a strong fluttering sensation. I called 911 with my cellular phone and here I am.”

History of Present Illness:

B.G. is a 52 yo man who was brought to the emergency room by paramedics following symptoms of dyspnea, dizziness, and palpitations. When questioned about his recent medical history, he reports a sudden, unintentional loss in weight of approximately 10 pounds over the past two months and nearly 15 pounds over the last four months. “I’ve been eating like an elephant, but I’ve been losing weight,” he reports. A few months ago, he began experiencing palpitations that came and went, but were not associated with chest pain. However, he notes that, sometimes, his “heart seems to beat too fast and too hard” and disproportionate to the activity in which he is engaged. Sometimes, it begins when he is sitting and watching TV or reading a magazine. He has also noticed that it has been “difficult getting some kinds of food down for the past week” and that he “had planned to see a doctor about that soon.”

“My wife also tells me that I have been on edge and a bit short with her lately. I agree that I have not been myself mentally.”

Past Medical History:

• Migraine headaches 9 years

• History of herpes simplex infections on lips and corners of mouth

• HTN 3 years

Family History:

• Paternal grandfather and father diagnosed with prostate cancer; father’s cancer is currently in remission

• Half-sister had “thyroid problems with a goiter”

• Mother had arthritis and hyperthyroid disease

• One brother with type 2 DM who “takes pills”

Social History:

• Married and lives with wife of 30 years

• They had one daughter who was kidnapped and murdered in Aruba 6 months ago. The authorities have made no arrests to date and there are no suspects at this time.

• Works as an auto mechanic

• Previous smoker but quit 11 years ago

• Has an occasional beer with friends

• Denies use of illicit drugs, although he reports history of heroin and cocaine use as a young adult

• Admits to drinking “too much coffee” every day

• Physically very active and jogs 1–2 miles 3 or more days each week; also works out at the gym 1 day/week

Review of Systems:

• (+) occasional insomnia plus increased sensitivity to heat, fatigue, and decreased exercise tolerance for 1 week

• Reports that “hair seems to be falling out faster than usual” for past month

• (-) headache, cough, blurred or double vision, eye pain or sensitivity to light, excessive tearing or discomfort in the eyes, fever or chills, muscle weakness, diarrhea, chest pain, changes in libido or sexual performance, concentration problems, “shakiness,” rashes or other skin lesions, painful swallowing, tenderness/pain in the neck, difficulty with urination, edema, recent fainting spells, and recent respiratory infection

Medications:

• Acetaminophen 500 mg + aspirin 500 mg + caffeine 130 mg PO QD PRN

• Atenolol 25 mg PO QD

• Multivitamin 1 tablet PO QD

Vaccinations: Unknown

Allergies: Morphine → intense pruritus

Physical Examination:

Vital Signs	Temp. = 98.8F oral BP = 98/70 mmHg supine RR = 20 breaths/minute and unlabored HR = 130-170 beats/minute, irregular Height = 5’10” Weight = 124 lbs
General	Patient is thin, tanned, white male who appears slightly short of breath. He is cooperative and answers all questions appropriately.
Skin	Skin very warm, soft, intact, and moist Normal turgor and color Hyperpigmented lesions on upper back and lower extremities Hair is fine, velvety, and sparse on crown of head No evidence of rash, ecchymoses, petechiae, edema, or cyanosis
HEENT	PERRLA EOMI Positive: eyelid lag bilaterally, R > L Positive: mild proptosis bilaterally Fundi benign TMs intact Tongue and oral mucous membranes moist without erythema, exudates, or lesions Cold sore on right upper lip
Neck, Lymph Nodes	Neck supple Positive: smooth, diffusely enlarged thyroid Negative: JVD, carotid bruits, or cervical/axillary/inguinal adenopathy
Lungs	Lungs clear bilaterally No wheezes or crackles
Heart	Irregular rhythm Tachycardic without murmurs No S3 or S4 heard No rubs heard
Abdomen	Soft, non-tender, non-distended Positive bowel sounds in all four quadrants Negative: hepatosplenomegaly, masses, bruits
Genitalia, Rectum	Normal male genitalia Prostate slightly enlarged, but no nodules noted Guaiac-negative stool
Musculoskeletal, Extremities	2+ DP pulses bilaterally Negative joint tenderness, peripheral edema, cyanosis, or clubbing Full ROM No muscle weakness in proximal muscle groups No femoral bruits
Neurological	Alert & oriented to person, place, and time DTRs 3+ at knees No tremor observed with fingers extended CNs II-XII intact Negative Babinski Sensory and motor levels appear intact

Laboratory Blood Test Results:

Serum Sodium	142 mEq/L	RBC	4.9 million/mm^3	WBC	7,700/mm^3
Serum Potassium	4.0 mEq/L	Hct	42%	ESR	6 mm/hr
Serum Chloride	108 mEq/L	Hb	14.6 g/dL	Total Cholesterol	68 mg/dL
Serum Calcium	8.6 mEq/L	Platelets	378,000/mm^3	Total T4	26.5 μg/dL
Glucose	NA	Serum Magnesium	1.8 mg/dL	Total T3	508 ng/dL
Creatinine	0.6 mg/dL	HCO3	27 meq/L	TSH	0.016 μU/mL
BUN	11 mg/dL	MCV	88 fL	FT4	57 pmol/L
AST	34 IU/L	ALT	31 IU/L	Total Bilirubin	1.0 mg/dL

Electrocardiogram:

• Atrial fibrillation

• Sinus tachycardia

• Negative: Left ventricular hypertrophy

Thyroid Ultrasound: Marked vascularity of the thyroid

Radioactive Iodine Uptake Test: 53% 123Iodine absorbed after 5.9 hours

Thyroid-Stimulating Hormone Receptor Antibody Test: Positive

Chest X-Ray: Clear

Exophthalmometry:

• 20% greater than expected, R eye

• 11% greater than expected, L eye

Case Study Questions:

1. Which is a more appropriate diagnosis and why: primary hyperthyroidism, secondary hyperthyroidism, or tertiary hyperthyroidism?

2. Why can a pituitary tumor be excluded as a potential cause of hyperthyroid disease in this patient?

3. Why is this patient taking a combination drug regimen of acetaminophen, aspirin, and caffeine?

Answer 1

>The more appropriate diagonosis in detail study of the case, is the primary hyperthyroidism,while the classification can see more prompt in hypothyroidism, like primary ,secondary and tertiary. In this case the family history shows various events with the genetic factors and stressful life events role , which is one of the main reason in hyperthyroidism. hypothyroidism occurs in approximately 2% of women and 0.2% in men; the highest frequency is in 30-50 year old age group.

> In this case the pituatory tumours was excluded because of the serum plasma and the whole blood chemistry studies and the physical examinations shows clear that it is a case excessive production of ,or sustained increase in the synthesis and release of thyroid hormones by the thyroid gland. T3-(in patient) 508 ng/dl.,normal value(110-230ng ) T4(in patient) 26.5ug/dl.-normal value( 5-12ug/dl)TSH ( in patient) 0.016uU/ml.,normal value( 0.3-5.4uU/ml).

>Acetaminophen used to block the pain impulses as the client complaint those from her first intraction with medics, it inhibits by synthesis of prostaglanddin in CNS or of other substance that sensitize pain receptors to mechanical or chemical stimulation.Aspirin is used to reduce the risk of any ustable angina as it work as same as acetaminophen and it also reduce the risk of recurrent transient ischemic attacks and stroke or death in patients at risk.