ACNP Problems II Case Studies I and II - Weebly



ACNP Problems Case Studies I and IILaura LangenhopWright State UniversityACNP Problems II Case Studies I and II1. What are the potential etiologies of this patient’s symptoms? (That is, what are the differential diagnoses?) Provide rationale for your answer. Use a variety of references. Prioritize your list from most likely diagnosis to least likely diagnosis.Differential diagnoses for this patient include meningitis, pheochromocytoma, migraine, subarachnoid hemorrhage, and thyroid storm. The most common cause of hyperthyroidism and thyroid storm is Grave’s disease (Tintinalli et al., 2011). The patient in this case was diagnosed with Grave’s disease one month prior to hospital admittance. Patients who are at risk for thyroid storm are those who have received radioactive iodine, who have had surgery, those who have given birth, those with severe illnesses such as diabetes mellitus, and those with an infection (Lee & Masharani, 2012). Thyroid storm occurs most frequently in younger women (Tintinalli et al., 2011). This patient is at risk for thyroid storm because of her young age and also because the patient received radioactive iodine treatment several days prior to hospital admittance (Hampton, 2013). Thyroid storm is an exacerbation of thyrotoxicosis, or the overabundance of thyroid hormone (Hampton, 2013). The thyroid hormones play a major part in thermogenic and metabolic homeostasis (Hamptom, 2013). The lack of regulation of the thyroid hormones causes the metabolic and thermoregulatory responses to be altered. Symptoms of thyroid storm include a fever ranging from 38 degrees Celsius to 41 degrees Celsius, sweating, photophobia, tachycardia, delirium, agitation, restlessness, nausea, vomiting, diarrhea, oligomenorrhea, abdominal pain, and sometimes coma (Lee & Masharani, 2012). In this case, the patient’s symptoms that align with the signs and symptoms of thyroid storm include a fever of 38.1 degrees Celsius, tachycardia, fatigue, weight loss, photophobia, oligomenorrhea, headache, and an enlarged thyroid with a prominent bruit. With the addition of the thyroid function tests, the diagnosis of thyroid storm can be suspected in this patient (Hamptom, 2013). Thyroid storm occurs when the thyrotropin receptor antibodies stimulate large amounts of uncontrolled thyroidal synthesis and increase the secretion of thyroid hormones (Tintinalli et al., 2011). Normal thyroid function tests include a thyroid stimulating hormone (TSH) level between 0.5-5.0 mIU/mL, a triodothyronine (T3) level between 70-195 ng/dL, a free thyroxine index (FTI) level 0.9-2.4 ng/dL, and a serum thyroxine (T4) level between 5-12 mcg/dL (Hampton, 2013). The patient’s previous outpatient thyroid function tests showed a low level of TSH and an elevated T4, FTI, T3, and the four-hour uptake was 58.8 %. In the emergency room, the TSH was within normal limits at 0.92 mIU/mL, while the T3 and T4 were still elevated with an incalculable FTI. The laboratory work received in the emergency room is consistent with thyroid storm with the main findings being an elevated T3, T4, and FTI (Weiss & Refetoff, 2005). The patient was previously diagnosed with Grave’s disease. The patient was treated with radioactive iodine, which is typically given for a “hot thyroid nodule”, a portion of the thyroid consuming a large amount of iodine (Flechas, 2012). When the thyroid consumes large amounts of iodine, the body does not realize it and believes there is not enough iodine in the system and therefore large amounts of T4 are secreted in order to compensate for it (Flechas, 2012). Radioactive iodine is given in order to counteract the consumption of iodine from the thyroid and reduce T4 levels. However, use of radioactive iodine without proper anti-thyroid regimen results in a rare complication, thyroid storm, as seen by the patient is this case study (Flechas, 2012). The patient presented to the emergency room with a headache and pain radiating to her neck and a fever. The headaches and neck pain may signal meningitis. Meningitis can be either bacterial or viral in nature (Putz, Hayani, & Zar, 2013). Meningitis is defined as inflamed meninges with an increased number of white blood cells in the cerebral spinal fluid (Putz, Hayani, & Zar, 2013). Patients with meningitis have symptoms of headache, fever, nuchal rigidity, photophobia, extremity weakness, and possible lymphadenopathy. Nuchal rigidity is a highly sensitive test. With the absence of nuchal rigidity, a normal white blood cell count and altered mental status make the diagnosis of meningitis unlikely (Putz, Hayani, & Zar, 2013). Pheochromocytoma is another differential diagnosis. A pheochromocytoma is a well vasculcularized tumor originating from the adrenal medulla or the carotid body (Neumann, 2012). Pheochromocytoma produces catecholamine’s causing palpitation, diaphoresis, and headaches. Patients with pheochromocytoma also have hypertension and tachycardia. Catecholamine crises from a pheochromocytoma can cause pulmonary edema, arrhythmias, and intracranial hemorrhage (Neumann, 2012). These attacks typically occur in less than an hour and may be precipitated by surgery, positional changes, exercise, pregnancy, urination, and various medications such as tricyclic antidepressants (Neumann, 2012). The patient in this scenario has a headache, fever, tachycardia, and hypertension. Urine catecholamines would be ordered to diagnose a pheochromocytoma (Neumann, 2012). Plasma metanephrines may also be ordered. A computerized-tomography scan of the adrenal glands also would be ordered to view the tumor (Nuemann, 2012). The patient in this scenario has a mild tachycardia, mild hypertension, and is without palpitations and diaphoresis. Pheochromocytoma is a possible differential diagnosis, but due to the patient’s thyroid function studies and recent iodine radiation treatment, the likely diagnosis is thyroid storm (Nuemann, 2012). Subarachnoid hemorrhage should be considered in a patient with a severe headache. A subarachnoid hemorrhage causes blood to compress against brain tissue leading to neurologic deficits (Greenberg, Aminoff, & Simon, 2012). Another issue that may arise from a subarachnoid hemorrhage is vasospasms leading to re-injury and ischemia (Greenberg, Aminoff, & Simon, 2012). Typically, patients with severe headaches admit to the emergency room without signs and symptoms of neurologic problem. In this case, the patient presented with a severe headache with a history of migraines. The patient has photophobia that has occurred over the last month that has recently worsened. Through physical examination and thyroid function testing, subarachnoid hemorrhage is a possible diagnosis but the cause of the patient’s headache is most likely related to a different etiology (Greenberg, Aminoff, & Simon, 2012). Since the patient has a history of migraines that are difficult to control, a migraine headache is also a differential diagnosis for this case presentation. Migraine headaches present with photophobia, phonophobia, nausea, vomiting, and are typically unilateral in nature (Stern, Cifu, & Altkorn, 2010). The patient also has photophobia that has occurred over the last month compounded with nausea and vomiting. The patient was without an aura or phonophobia. The differences in this case are the patient’s other signs and symptoms. The patient has a fever, abnormal thyroid function tests, thyroid bruit, right upper abdominal pain, tachycardia, and high blood pressure. Though the patient’s headache could be a migraine, the actual etiology of the patient’s problems is most likely from thyroid storm (Stern, Cifu, & Altkorn, 2010). 2. Which of the following is not considered a diagnostic criterion for thyroid storm? Bold the correct answer. Provide rationale for your answer and why you eliminated the others.A. Nausea and vomitingB. TachycardiaC. TremorD. FeverE. Pulmonary EdemaThe diagnosis of thyroid storm can be difficult to make. Burch and Wartofsky developed a point system in order to distinguish between thyrotoxicosis and thyroid storm (Tintinalli et al., 2011). The point system includes seven categories. These seven categories are congestive heart failure, atrial fibrillation, heart rate, fever, gastrointestinal-hepatic dysfunction, precipitating events, and central nervous system effects (Paulson & Hollenberg, 2012). A total score >45 is suggestive of a patient having thyroid storm (Tintinalli et al., 2011). The patient’s score in this case is 55, based on clinical signs and symptoms. Of the categories listed, nausea and vomiting, tachycardia, fever, and pulmonary edema are all considered to be a part of the diagnostic criteria for the diagnosis of thyroid storm (Paulson & Hollenberg, 2012). Metabolic and thermoregulatory dysfunction can cause the patient to present with abdominal issues, fever, and tachycardia with the absence of tremor. A patient may present with a tremor along with other symptoms, but it is not considered a diagnostic criterion (Paulson & Hollenberg, 2012; Tintinalli et al., 2011). In the “central nervous system effects” category, the only diagnostic criteria for thyroid storm are agitation, delirium, psychosis, lethargy, seizure, and coma (Paulson & Hollenberg, 2012). Tremor is not considered a diagnostic criterion for the diagnosis of thyroid storm (Paulson & Hollenberg, 2012). 3. Based on this patient’s symptoms and diagnostic studies, which of the following management strategies is not appropriate? Provide rationale for your answer and why you eliminated the others. A. Ablation 1311 (RAI)B. ThyroidectomyC. B-Blocker and thionamide (popylthiouracil or methimazole)D. Lugol SolutionE. CorticosteroidsThe management strategy that is inappropriate for the patient is the iodine ablation (RAI). Following thyroid storm, patients need to wait until they are in a euthyroid state before they can consider receiving RAI (Tintanalli et al., 2012). Typically, patients receive a RAI ablation after a thyroidectomy in order to eliminate thyroid remnants and neoplasms, and to search for persistent carcinomas (Schlumberger et al., 2012). An ablation following a thyroid storm is contraindicated because the iodine administered into the thyroid gland can have an adverse effect and worsen the thyroid function. By deteriorating the thyroid function, the thyroid storm could become detrimental, placing the patient at risk for worsening symptoms and medical instability (Tintinalli et al., 2012; Schlumberger et al., 2012). Beta-blockers are used in patients with thyroid storm to control the excessive adrenergic response (Lee & Masharani, 2012). Medications, such as Propanolol or Atenolol, are used to help prevent the conversion of T4 to T3 (Lee & Marsharani, 2012). Beta-blockers conversely help to treat tachycardia as well as high blood pressure in patients. Beta-blockers are used until Free T4 and T3 levels return to normal (Lee & Marsharani, 2012). In the state of Ohio, an advanced practice registered nurse with a certificate to prescribe (CTP) may prescribe Atenolol and Propranolol (The Ohio Board of Nursing, 2014). Anti-thyroid medications, Popylthiouracil (PTU) and Methimazole, are also considered when treating thyroid storm. PTU and Methimazole are considered hormone synthesis blockers (Huecker & Danzl, 2011). PTU is used because it prevents the conversion of T3 to T4 (Lee & Marsharani, 2012). Both PTU and Methimazole can only be given orally, via nasogastric tube, or rectally (Huecker & Danzl, 2011). A rare side effect of PTU and Methimazole is agranulocytosis and therefore routine complete blood cell counts should be taken. In the state of Ohio, an advanced practice registered nurse with a CTP may prescribe PTU and Methimazole (The Ohio Board of Nursing, 2014). Lugol’s solution can also be administered during a thyroid storm. Lugol’s solution is a saturated solution of potassium iodide (Weiss & Refetoff, 2005). It acts by stabilizing the thyroid hormones in addition to the anti-thyroid drug regimen. The administration of anti-thyroid medications one hour prior to Lugol’s solution is recommended in order to prevent new hormone synthesis and further exacerbation of the thyroid storm (Weiss & Refetoff, 2005). T3 levels should return to normal within one to five days following administration of anti-thyroid medications and Lugol’s solution (Weiss & Refetoff, 2005). Corticosteroids also play a role in the treatment of thyroid storm (Hampton, 2013). Like Propanolol, corticosteroids block the conversion of T4 to T3 further decreasing the T3 levels. Corticosteroids also aid in the treatment of adrenal insufficiency, a complication of thyroid storm (Hampton, 2013). In the state of Ohio, an advanced practice registered nurse with a CTP may prescribe Corticosteroids (The Ohio Board of Nursing, 2014). Case Study 21. What is the most appropriate next step in this patient’s diagnostic evaluation? Provide rationale for your answer.A. Contrast-enhanced CT scan of the brainB. Magnetic Resonance Imaging (MRI)C. Lumbar Puncture (LP) with cerebrospinal fluidD. ElectroencephalogramE. No further diagnostic testingA computed tomography (CT) scan is ordered on patients to assess and rule-out intracranial hemorrhage, skull fractures, and distinguish between a hemorrhagic and ischemic stroke (Tintinalli et al., 2011). A CT scan previously ordered in this case scenario was negative for intracranial hemorrhage, hydrocephalus, or other abnormalities. Therefore, it would be in the best interest of the patient not to re-order the test in order to prevent more radiation exposure (Tintanalli et al., 2011).An MRI could be considered in patients with an acute cerebrovascular accident, spinal cord compression, hip fracture, cerebral venous sinus thrombosis, and carotid and vertebral artery dissection (Tintanalli et al., 2011). An MRI is a good diagnostic tool for tissue discrimination and it can visualize bones, ligaments, tendons, the heart, vessels, and solid abdominal pelvic organs well (Tintanalli et al., 2011). Though an MRI is a great test for many diagnoses, in this patient’s case a lumbar puncture would be a better diagnostic test. Since the patient is admitted for probable bacterial meningitis, a lumbar puncture would be a more suitable test (Tintanalli et al., 2011). An electroencephalogram (EEG) is useful to patients in critical care settings for monitoring brain function post cardiac arrest, detecting ischemia, and monitoring treatment of epilepsy (Winn, 2011). In patients with recent possible seizure activity, an EEG is particularly useful in diagnosing seizures as well as monitoring the progress of a patient’s treatment (Winn, 2011). However, this patient would not require an EEG due since the patient is without seizure activity at this time (Winn, 2011). Recommendations for initial testing in patients with suspected meningitis include blood cultures and a lumbar puncture (Chaudhuri et al., 2008; IDSA, 2004). A lumbar puncture is recommended initially in order to rule-in the diagnosis of bacterial meningitis and in order to treat with proper antibiotic therapy. Morbidity and mortality increase if there is delay in therapy for patients with bacterial meningitis (Chaudhuri et al., 2008). Therefore, it is imperative that patients have a lumber puncture performed early. The patient in this case study would require a lumber puncture as the next diagnostic test of choice (IDSA, 2004). 2. Which of the following is this patient’s most likely diagnosis? Provide rationale for your answer.A. Viral MeningitisB. Fungal MeningitisC. Bacterial MeningitisD. Mycobacterial MeningitisE. Noninfectious Meningeal Irritation The patient’s most likely diagnosis is bacterial meningitis. The diagnosis can be made based on the patient’s physical symptoms and laboratory findings. First, the patient presents with a headache, confusion, neck stiffness, and a temperature of 100.9 degrees Fahrenheit. All of these symptoms should point the nurse practitioner towards a possible meningitis diagnosis (Roos & Brosch, 2012). The next piece of the diagnosis comes from the results of the lumbar puncture. The patient has an opening pressure of 270 mmH20, a white blood cell count of 1,050 cells/mcL, and a protein level of 81 mg/dL. The opening pressure reading of 270 mmH20 signifies an elevated pressure in the cerebral spinal fluid (CSF) that can be correlated with inflammation (Putz et al., 2013). A patient with an opening pressure >180 mmH20 correlates with a patient who has bacterial meningitis (Chin-Hong & Guglielmo, 2014). The patient’s white blood cell count in her cerebral spinal fluid (CSF) is elevated placing the patient at risk for either viral or bacterial meningitis. The white blood cells found in the CSF are predominately neutrophils. Because of the predominance of neutrophils, the patient most likely has bacterial meningitis (Chin-Hong & Guglielmo, 2014). The patient’s protein level is also elevated, placing the patient at risk for bacterial meningitis. The patient’s protein level is 81 mg/dL. Protein levels found in CSF >80 mg/dL is diagnostic for bacterial meningitis as well as all other forms on meningitis. The patient’s blood glucose level from the CSF is elevated at 121 mg/dL making the glucose level inconsistent with a certain type of meningitis (Chin-Hong & Guglielmo, 2014). The serum blood glucose is also elevated at 307 mg/dL. Using the elevation in both blood glucose levels, the serum to CSF/blood glucose ratio can be calculated. This patient’s ratio is 0.39. A ratio that is <0.4 is considered diagnostic for bacterial meningitis (Roos & Brosch, 2012).In summary, the patient is considered to have bacterial meningitis based on the CSF levels. First, the white blood cell count is elevated with the majority of the cells being neutrophils. Secondly, the opening pressure is elevated revealing inflammation. Third, the protein level is elevated. Finally the CSF/serum glucose ratio is <0.4 (Chin-Hong & Guglielmo, 2014; Roos & Brosch, 2012). 3. Based on the gram stain, which of the following antibiotic regimens is the most appropriate in this patient? Provide rationale for the answer.A. Penicillin GB. CeftriaxoneC. Ceftriaxone and VancomycinD. Ampicillin and CefotaximeE. CefepimeIn patients 50 years of age or older, the most common pathogens for acute bacterial meningitis are Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes, and gram-negative bacilli (Chin-Hong & Guglielmo, 2014). The patient’s gram-stain revealed gram-positive cocci in pairs with many polymorphonuclear leukocytes and a few mononuclear leukocytes (Chin-Hong & Guglielmo, 2014). Neisseria meningitides is considered to be a gram-negative microbial (Chin-Hong & Guglielmo, 2014). Listeria monocytogenes is a microbial seen with gram-positive rods. Finally, Streptococcus pneumoniae is considered a microbial with gram-positive cocci (Chin-Hong & Guglielmo, 2014). Streptococcus pneumoniae is considered the probable microbial in this case study. The recommended treatment for patients with meningitis caused by Streptococcus pneumoniae is Vancomycin and a third generation cephalosporin (Infectious Disease Society of America [IDSA], 2004). Of the choices given, Vancomycin and Ceftriaxone should be ordered to treat the patient’s bacterial meningitis (IDSA, 2004). Once the pathogen has truly been identified as Streptococcus pneumoniae, the patient can be switched to Penicillin G (Chin-Hong & Guglielmo, 2014; IDSA, 2004). Intravenous Vancomycin would be ordered at 15 mg/kg/dose every eight hours and intravenous Ceftriaxone would be ordered one gram every 24 hours (Chin-Hong & Guglielmo, 2014). In the state of Ohio, a nurse practitioner with a certificate to prescribe can prescribe Vancomycin and Ceftriaxone (The Ohio Board of Nursing, 2014). 4. Complete the following table. Provide references at the end of the table. MeasurementNormalBacterial MeningitisAseptic Meningitis (Viral)Granulomatous Meningitis (Mycobacterial, Fungal)Spirochetal MeningitisOpening Pressure (mmH20)70-180 mmH20>180 mmH20Slightly elevatedModerately elevatedNormal to slightly elevatedWBC’s0-5 lymphocytes200-20,000 cells/mcL(neutrophils predominate)25-2,000 cells/mcL (mostly lymphocytes)100-1,000 cells/mcL(mostly lymphocytes)100-1,000 cells/mcL(mostly lymphocytes)Glucose (mg/dL)45-85 mg/dL<45mg/dLNormal of Low<45 mg/dLNormalProtein (mg/dL)15-45 mg/dL> 50 mg/L>50 mg/dL>50 mg/dL>50 mg/dLTable 1 Adapted from (Chin-Hong & Guglielmo, 2014). Common problems in infectious diseases & antimicrobial therapy. In Papadakis & McPhee, Current Diagnosis and Treatment. New York, NY: McGraw Hill.5. Should this patient receive adjuvant therapy with dexamethasone? Explain your answer. Any patient with suspected bacterial meningitis should receive dexamethasone treatment (Infectious Disease Society of America [IDSA], 2004). The administration of Dexamethasone has shown to affect morbidity and mortality. Dexamethasone, a steroid, aids in the decrease of meningeal inflammation (Chaudhuri et al., 2008). Administering dexamethasone to patients with bacterial meningitis is said to decrease cerebral edema, decrease intracranial pressure, stabilize cerebral blood flow, and decrease cerebral vasculitis (IDSA, 2004). The European Federation of Neurological Sciences has written the most recent guidelines on bacterial meningitis (Chaudhuri et al., 2008). Dexamethasone is recommended in the treatment of bacterial meningitis in order to decrease the risk of subarachnoid inflammation and blood brain barrier inflammation permeability (Chaudhuri et al., 2008). Dexamethasone is said to work only if given prior to initiation or in co-commitment administration of antibiotic therapy (Hessen, Baustian, Opal, Asad, & Wijdicks, 2011). The recommended dose of Dexamethasone is 10 mg every six hours intravenously for four days. In the state of Ohio, an advanced practice registered nurse with a CTP may prescribe Dexamethasone (The Ohio Board of Nursing, 2014).ReferencesChaudhuri, A., Martin, P. M., Kennedy, P. G., Seaton, R. A., Portegies, P., Bojar, M., & Steiner, I. (2008). EFNS guideline on the management of community-acquired bacterial meningitis: report of an EFNS Task Force on acute bacterial meningitis in older children and adults. European Journal of Neurology, 15, 649-659. , P. V., & Guglielmo, B. G. (2014). Common problems in infectious disease (antimicrobial therapy. In M. A. Papadakis, S. J. McPhee, & M. W. Rabow (Eds.), Current medical diagnosis & treatment). New York, NY: McGraw Hill.Flechas, J. D. (2012). Iodine supplementation and monitoring to ensure patient health and safety. Journal of Restorative Medicine, 1(1), 49-55. , D. A., Aminoff, M. J., & Simon, R. P. (2012). Clinical neurology (8th ed.). Retrieved from , J. (2013). Thyroid gland disorder emergencies. AACN Advanced Critical Care, 24(3), 325-332. , M. T., Baustian, G. H., Opal, S. M., Asad, S., & Wijdicks, E. (2011). Bacterial meningitis in adults. Retrieved from {%22scope%22:%22all%22,%22query%22:%22bacterial%20Meningitis%22}Huecker, M. R., & Danzl, D. F. (2011). Metabolic and endocrine emergencies. In C. K. Stone, & R. L. Humphries (Eds.), Current diagnosis & treatment emergency medicine (7th ed.). Retrieved from Disease Society of America. (2004). Practice guidelines for bacterial meningitis. Retrieved from , G. A., & Masharani, U. (2012). Thyroid gland disorders. In A. L. Lalwani (Ed.), Current diagnosis & treatment in otolaryngology: head and neck surgery (3rd ed.). Retrieved from , H. P. (Ed.). (2012). Pheochromocytoma. Harrison’s principles of internal medicine (18th ed.). Retrieved from , J. M., & Hollenberg, A. N. (2012). Thyroid emergencies. In S. C. McKean, J. J. Ross, D. D. Dressler, D. J. Brotman, & J. S. Ginsberg (Eds.), Principles and practice of hospital medicine). Retrieved from , K., Hayani, K., & Zar, F. A. (2013). Meningitis. Primary care: clinics in office practice, 40(3), 707-726. Retrieved from {%22scope%22:%22all%22,%22query%22:%22meningitis%22}Roos, K. L., & Brosch, J. R. (2012). Meningitis & encephalitis. In S. C. McKean, J. J. Ross, D. D. Dressler, D. J. Brotman, & J. S. Ginsberg (Eds.), Principles and practice of hospital medicine). Retrieved from , M., Catargi, B., Borget, I., Dandreis, D., Zerdoud, S., Bridji, B., ... Benhamou, E. (2012, May 3). Strategies of radioiodine ablation in patients with low-risk thyroid Cancer. New England Journal of Medicine, 366(18), 1663-1673. Retrieved from , S. D., Cifu, A. S., & Altkorn, D. (2010). Symptom to diagnosis: an evidence based guide (2nd ed.). Retrieved from , J. E., Stapczynski, S., Ma, O. J., Cline, D. M., Cydulka, R. K., & Meckler, G. D. (Eds.). (2011). Tintinalli’s emergency medicine: a comprehensive guide (7th ed.). Retrieved from Ohio Board of Nursing (2014). The formulary developed by the Committee on Prescriptive Governance. Retrieved form , R. E., & Refetoff, S. (2005). Thyroid disease. In J. B. Hall, G. A. Schmidt, & L. D. Wood (Eds.), Principles of critical care (3rd ed.). Retrieved from , H. R. (2011). Continuous electroencephalography in neurological-neurosurgical intensive care. In H. R. Winn (Ed.), Youmans Neurological Surgery (6th ed.). Retrieved from {%22scope%22:%22all%22,%22query%22:%22Electroencephalogram%22} ................
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