Tracy Hill MSN Portfolio



Chief Complaint:Follow-up on HypothyroidismHistory of Present Illness:TE is a 34 y.o. white female who is a primary care patient of HealthCare Access, under the care of Lori Winfrey, APRN. TE presents for a scheduled follow-up appointment for her hypothyroidism. She was initially seen in the clinic about 6 weeks prior for a well-woman exam; she had not seen a provider for health care in about 6 years. At her initial visit, she disclosed a history of hypothyroidism, and had previously taken levothyroxine, but had not been on any medication over the last 6 years. TE reports a loss of insurance and a dispute with per PCP as the reason she had not been treated for her hypothyroidism in such a long time. Multiple labs were drawn at the initial visit, with a scheduled follow-up to review the labs scheduled 1 week later. A review of her labs, among other results, indicated a TSH of 424.80uLu/ml and a Free T4 of 0.13 ng/dl! The patient was started on levothyroxine 50mcg/day and scheduled for a follow-up visit. On day of her appointment, she reports a decrease in symptoms. She reports an increase in energy, denies fatigue, and overall feeling better with increased activity. She reports “I had been sleeping until 1000 or 1100 and still not feeling rested, and now I can get up at 0600 and feel pretty good. I didn’t realize how tired and fatigued I was all the time until now.”Review of Systems (Mosby, 2011):Constitutional: No weakness, fatigue; no decreased activityENT: NegativeRespiratory: NegativeCardiovascular: NegativeGastrointestional: NegativeGenitourinary: NegativeGynecologic: NegativeHematology/Lymphatics: NegativeEndocrine: Negative except as documented in HPIImmunologic: NegativeMusculoskeletal: c/o bilateral foot pain; reports hx of “flat feet”; saw podiatrist when she worked at Berry Plastics and they recommended orthotics.Integumentary: NegativeNeurologic: Alert and Oriented x 4.Psychiatric: NegativePast Medical History: -Hypothyroidism (untreated last 6 years)-Dyslipidemia (treated with lovastatin 20mg daily)Surgical History: Tubal Ligation (date unknown)Social History: Lives at home independently with spouse of 15 years; drinks alcohol rarely, 1-2 times per year; occasionally exercises; Current daily cigarette smoker, 1/3 pack per day x 15 years – reports she is trying to quit; denies substance abuse. Family History with Genogram: See Genogram attachmentAllergies: NKDAMedications: -Levothyroxine 50 mcg daily for hypothyroidism-Lovastatin 20mg daily for dyslipidemiaPhysical Exam(Mosby, 2011)General: Alert and oriented, no acute distress; appropriate mood and affect for situation.Vital signs: Blood pressure: 122/92; heart rate: 80; RR- 12; SaO2 not obtained; Temp not obtained. Height: 162cm; Weight: 107 kg; BMI: 40.70.Eye: Pupils are equal, round, and reactive to lightHENT: Normocephalic; TM’s clear bilaterally- no redness, swelling, lesions, foreign bodies or discharge. Nose is symmetric, midline. No inflammation, deformity or lesions noted. Nares patent bilateral. Posterior pharynx moist, without erythema or exudate. Neck: Supple, non-tender, No JVD, no thyromegaly.Lymph Nodes - No lymphadenopathy.Respiratory: Lungs are clear to auscultation bilaterally. Respirations are even, non-labored. Symmetric chest was expansion.Cardiovascular: Normal heart rate,S1S2, no extra heart sounds; No murmur appreciated; 2+ pulses equal in all extremities. Capillary refill <3 seconds. No JVD, no carotid bruit. Gastrointestinal: Normoactive bowel sounds, abdomen soft and non-tender on palpation, no guarding, no rebound. Rectal exam deferred.Genitourinary: deferredMusculoskeletal: Full ROM with head, neck, spine, pelvis, bilateral upper and lower extremities; Normal gait. Lowe extremity exam: bilateral plantar foot pain, tender on palpation, normal ROM).Integumentary: Skin uniformly pink, warm, dry. No edema. Neurologic: Alert, oriented. Normal sensory. Normal motor function. Cranial Nerves II-XII intact. Psychiatric: Cooperative, appropriate mood and affect; Normal judgment.Pertinent Diagnostic Tests-Lab tests: TSH (7/12)- 424.80 ulU/ml; Free T4: 0.13ng/dLTSH (9/12) – 64.84 ulU/ml; Free T4: 0.68 ng/dLCBC/COMP: (7/12) Normal except:RBC: 3.83 x 10^6 cmmHGB: 12.5 g/dLHCT: 37.4%AST (SGOT) 43 Unit/LCholesterol (7/12) 289mg/dL; HDL 53 mg/dL; Triglycerides 119 mg/dL; LDL 212 mg/dLDifferential Diagnosis:Primary Hypothyroidism – (244.9) –Subclinical initial presentation with nonspecific symptoms of weakness, lethargy, depression and mild weight gain; PE may show dry skin, thick tongue, eyelid edema and bradycardia; Elevated TSH and low free T4.Anemia (281.9)Iodine hypothyroidism (244.2)Chronic Fatigue SyndromeDepression (780.71)Fibromyalgia (729.1)Dyslipidemia (272.9)Foot pain (729.5)Impression/Plan: Hypothyroidism – Currently taking Levothyroxine 50mcg daily; will increase to 100mcg/daily; will recheck TSH/T4 in 4-6 weeks (Levothyroxine has a long half-life of 1 week) and make changes accordingly. The patient is educated on knowing that daily lifelong treatment with thyroid hormone will be required, and once adequate levels are achieved, should be measured at least yearly. Dyslipidemia – treated with lovastatin 20mg Qhs; continue lovastatin; will recheck lipids/LFT’s in 6 months.Foot Pain – will get OTC shoe inserts, try ice massage and stretches; get shoes with better arch supports if possible; FU in 1 month to re-evaluate.Reflection of care providedThis patient was discharged home from the outpatient office setting. I spent approximately 45 minutes obtaining and reviewing the H &P, performing a ROS, physical assessment, plan and interventions. A thorough HPI and review of systems, as appropriate to this setting, was obtained. The patient was pleasant and cooperative. Although the diagnosis of hypothyroidism had already been made, and the patient had a previous history of the same, although untreated, I was able to independently formulate my differential diagnosis and develop the plan of care with minimal assistance of my preceptor. I was a little unsure about how much to adjust the dosage of levothyroxine at this visit and did consult with my preceptor about it. She recommended increasing the dosage to 100mcg daily from 50 mcg daily, which I did. Probably if I were practicing independently, I would have increased the dosage to 75mcg daily before going up to 100 mcg daily. There was quite an improvement in her TSH and Free T4 levels over the 2 month period. According to Epocrates (2011) the dosage of levothyroxine should be adjusted in increments of 12.5 to 25 mcg to normalize TSH – this was a 50 mcg dose increase. Epocrates also states that the main complication of treatment is over-replacement of thyroid hormone, which increases the risk of osteoporosis and atrial fibrillation (Epocrates, 2011). Next time, I will feel more confident in making a recommendation based on EBP to present to my preceptor. I hope that I am working at HCA when this patient has her follow-up appointment, so I can see the results of her dosage changes. At her 6 month follow-up, I would also hope to see improvement in her cholesterol levels as well, since untreated or undertreated hypothyroidism can contribute to dyslipidemia, especially elevated LDL ( pt level was 212mg/dl). Overall, this was a good learning experience and positive interaction. I felt like this experience helped me grow when reflecting on the detail that went into providing care, documentation and developing a plan of care. ReferencesButtaro, TM., Trybulski, J., Bailey, P.P., & Sandberg-Cook, J. (2008). Primary care: A collaborative practice (3rd ed.). St. Louis: Elsevier-Mosby.Epocrates (2011). Epocrates Essentials from Epocrates mobile application. [Diseases>Hypothyroidism>Differential diagnosis]. Retrieved from (2011). Epocrates Essentials from Epocrates mobile application. [Diseases>Hypothyroidism>Differential diagnosis]. Retrieved from , F.E. (2012). Ferri’s clinical advisor instant diagnosis and treatment. St. Louis: Elsevier-Mosby. ................
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