NURS 6501 Knowledge Check: Endocrine Disorders

	Scenario 1: Syndrome of Antidiuretic Hormone (SIADH) A 77-year-old female was brought to the clinic by her daughter who stated that her mother had become slightly confused over the past several days. She had been stumbling at home and had fallen twice but was able to walk with some difficulty. She had no other obv ious problems and had been eating and drinking. The daughter became concerned when she forgot her daughter’s name, so she thought she better bring her to the clinic. HPI: Type II diabetes mellitus (DM) with peripheral neuropathy x 30 years. Emphysema. Situational depression after death of spouse 6-months ago SHFH: – non contributary except for 40 pack/year history tobacco use. Meds: Metformin 1000 mg po BID, ASA 81 mg po qam, escitalopram (Lexapro) 5 mg po q am started 2 months ago Labs-CBC WNL; Chem 7- Glucose-102 mg/dl, BUN 16 mg/dl, Creatinine 1.1 mg/dl, Na+116 mmol/L, K+4.2 mmol/L, CO237 m mol/L, Cl–97 mmol/L. The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH). Question: 1.     Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH
	Selected Answer: SIADH syndrome of inappropriate antidiuretic hormone is a condition in excessive or high level of ADH is released from the pituitary gland. ADH helps the kidney regulate and conserve the amount of water in the body. it is a rare condition,that cause water retention in the body, and lower the sodium level in the blood. Hyponatremia is responsible for many of the complications, The causes are many,pain,disorder of the heart,thyroid gland,kidneys.or adrenal gland the use of certain drugs,disorders of the lungs and certain cancer Correct Answer:   SIADH is a group of symptoms that occurs when antidiuretic hormone (ADH, arginine vasopressin) is secreted in the absence of osmotic or physiologic stimuli. These stimuli include: Increased serum osmolality, decreased plasma volume, and hypotension. A decrease in plasma osmolality normally inhibits ADH production and secretion. SIADH is characterized by fluid retention, dilutional hyponatremia, hypochloremia, concentrated urine, and lack of intravascular volume depletion. SIADH is characterized by normal to increased blood volume in normoproteinemia, nonedematous, and hyponatremic patients with normal renal and endocrine function. Response Feedback: [None Given]

	Scenario 4: Hypothyroidism A patient  walked into your  clinic today with the following complaints: Weight gain (15 pounds), however has a decreased appetite with extreme fatigue,  cold intolerance, dry skin, hair loss, and falls asleep watching television. The patient also tearfulness with depression, and with an unknown cause and has noted she is more forgetful.  She does have blurry vision. PMH: Non-contributory. Vitals: Temp 96.4˚F, pulse 58 and regular, BP 106/92,  12 respirations. Dull facial expression with coarse facial features. Periorbital puffiness noted. Diagnosis: hypothyroidism. Question: What causes hypothyroidism?
	Selected Answer: Thyroid glands are butterfly glands located on the neck. It secretes thyroid hormones T3 and T4.It has a important influences on most import  body functions including heart, brain, heart, liver, kidney and skin.  It regulate the body temperature, heart rate, and metabolism.  The type of Hypothyroidism can be primary or secondary due to defect  from  pituitary gland . The causes of hypothyroid can be Hashimoto’s disease, medications, iodine endemic, congenital defect of the pituitary or thyroid.  The signs and symptoms are weakness, weight gain,cold intolerances,fatigue,bradycardia.,anaemia,hair loss, Correct Answer:   Patients with primary hypothyroidism have elevated TSH levels and decreased free hormone levels. Patients with elevated TSH levels (usually 4.5- 10.0 mIU/L) but normal free hormone levels or estimates are considered to have mild or subclinical hypothyroidism. The most common cause of hypothyroidism is autoimmune thyroiditis known as Hashimoto’s disease. Primary hypothyroidism is essentially the only disease that is characterized by sustained rises in TSH levels. As the TSH level increases early in the disease, conversion of T4 to T3 increases, maintaining T3 levels. In early hypothyroidism, TSH levels are elevated, T4 levels are normal to low, and T3 levels are normal. Response Feedback: [None Given]

Question 18

Needs Grading

	A 27-year-old man comes to the Veteran’s Administration Hospital at the insistence of his fiancée who accompanies him to the appointment. She tells the APRN that her fiancée has not “been the same” since he returned from his second tour in Iraq.  He was an infantryman with a local Marine Reserve unit and served 2 tours and was honorably discharged. Since his return, he has had difficulty sleeping, and says he “sleeps with one eye open” and fears sleep. Deep sleep brings vivid nightmares. He grudgingly admits to having experienced several traumatic events during his second tour of duty. He is unwilling to discuss them and will not reveal specific details. He is short tempered and irritable and is afraid to be around people as he doesn’t want to snap at people and alienate them. He startles easily at loud noises, especially the sounds of cars backfiring. He admits to thinking there are threats everywhere and spends an excessive amount of time searching for them but never finding any. He has intrusive memories almost every day and says he really isn’t interested in doing much of anything. He is very worried that these symptoms are irreparably hurting his relationship with his fiancée who he loves very much. The APRN diagnoses him with post-traumatic stress disorder (PTSD). Question 2 of 2: Briefly discuss the role glucocorticoids may have on the development of PTSD.
	Selected Answer: People with PTSD   have normal-low circulating cortisol levels despite a high Corticotropin-Releasing Factor (CRF) and ongoing stress. Cortisol reduces CRF production. With low cortisol levels, the levels of CRF levels increase and this stimulates the release of norepinephrine by the anterior cingulate. Norepinephrine also plays a major role in increasing blood pressure and a rapid heartbeat seen in individuals with flashbacks. Correct Answer: People with PTSD tend to have normal to low circulating levels of cortisol despite their ongoing stress and elevated levels of Corticotropin Releasing Factor (CRF). Cortisol leads to decreased production of CRF. If cortisol is low, then CRF continues to be high and stimulates norepinephrine release by the anterior cingulate. This norepinephrine contributes to the rapid heartbeat, and blood pressure elevations seen in people experiencing flashbacks. Response Feedback: [None Given]

Question 19

Needs Grading

	A 17-year-old male high school junior comes to the clinic to establish care. He recently moved from a relatively urban area to a very rural area and has just started his junior year in a new school. The mother states that she has noticed that her son has been frequently washing his hands and avoids contact with any dirty or soiled object. He uses paper towels or napkins over the knob on a door when opening it. According to the mother, this behavior has just appeared since moving. The patient, upon close questioning, admits that he is “grossed out” by some of the boys in the boys’ room since they use the toilet and do not wash their hand afterwards. He is worried about all the germs the boys are carrying around. Past medical history is noncontributory. Social history -lives with parents and 2 siblings in a house in a new town. Is an honors student. Based on these behaviors, The APRN thinks the patient has obsessive-compulsive disorder (OCD).   Question 1 of 2:   What is primary pathophysiology of OCD?
	Selected Answer: Among people with OCD, primary studies have indicated that its pathogenesis is associated with increased metabolic activity and flow of blood in the limbic structures, orbitofrontal cortex, thalamus, and caudate with a high right-sided dominance. There is also a pathophysiological brain circuit that comprises the orbitofrontal cortex, anterior thalamus, dorsal anterior cingulate cortex, and in the subregions of the basal ganglia of the putamen and caudate. Correct Answer: Neuroimaging studies have shown increases in blood flow and metabolic activity in the orbitofrontal cortex, limbic structures, caudate, and thalamus, with a trend toward right-sided predominance. There is a pathophysiological brain circuit that consists of the anterior thalamus, orbitofrontal cortex, dorsal anterior cingulate cortex, and predominately in the basal ganglia subregions of the caudate and putamen is involved in OCD. Response Feedback: [None Given]

Question 20

Needs Grading

	A 17-year-old male high school junior comes to the clinic to establish care. He recently moved from a relatively urban area to a very rural area and has just started his junior year in a new school. The mother states that she has noticed that her son has been frequently washing his hands and avoids contact with any dirty or soiled object. He uses paper towels or napkins over the knob on a door when opening it. According to the mother, this behavior has just appeared since moving. The patient, upon close questioning, admits that he is “grossed out” by some of the boys in the boys’ room since they use the toilet and do not wash their hand afterwards. He is worried about all the germs the boys are carrying around. Past medical history is noncontributory. Social history -lives with parents and 2 siblings in a house in a new town. Is an honors student. Based on these behaviors, The APRN thinks the patient has obsessive-compulsive disorder (OCD). Question 2 of 2:   Describe the role the dorsal anterior cingulate cortex (dACC) has in reinforcement of obsessive behaviors.
	Selected Answer: Neuroimaging studies indicate that individuals with OD have dACC hyperactivity. This is attributed to the fact that dACC is thought to be a primary center for receiving negative emotions, reinforces information, and integrates it to direct motivated behavior.   Correct Answer: Neuroimaging studies have demonstrated hyperactivity of the dACC in people with OCD as compared to controls. The dACC is thought to be a key center that receives negative emotion and reinforcing information and integrates that information to direct motivated behavior. Response Feedback: [None Given]

Sample Answer 3 for NURS 6501 Knowledge Check: Endocrine Disorders

Patient Information:

Initials: M.L

Age: 63 years

Sex: Female

Race: African American

Subjective

CC (chief complaint) “I have been having low levels of fasting blood sugar in the morning.”

HPI:

M.L is a 63-year-old presenting with a chief complaint of a low fasting blood sugar. She states that her morning fasting blood sugar has been as low as 50 in the past few weeks. The patient has a history of Hypertension, Diabetes mellitus, Hyperlipidemia, and Chronic Osteoarthritis. She mentions that her blood pressure has been high in the past few weeks. The BP at the time of presentation is 165/90 mm Hg.

Current Medications:

1. Women’s One a Day-Multivitamin once daily.
2. Chlorthalidone 25mg once daily.

• Fish Oil 1 tablet daily.

1. Amlodipine 5mg P.O once daily.
2. Atorvastatin 40mg P.O QHS daily.
3. Novolog 10 units with meals TDS.

• Aspirin 81mg P.O once daily.
• Lantus 25 units Subcutaneous at night.

1. Ergocalciferol 50,000 units P.O once a month.

Allergies: Allergic to Penicillin and Lisinopril.

PMHx: Immunization is up-to-date. The last Tetanus shot- 2 years ago. Positive medical history of Hyperlipidemia, Hypertension, Diabetes, and Chronic Osteoarthritis.

Soc Hx:

M.L is married and lives with her husband. She has three children aged 40, 36, and 29 years. She is a retired high school teacher and currently helps her husband to supervise their farm. Her hobbies include knitting and cooking. She has a history of alcohol use but stopped when she was 42 years after being diagnosed with HTN. She denies history of tobacco smoking or use of other drug substances.

Fam Hx: The patient’s mother had obesity and HTN, died from stroke. The elder brother has DM and HTN. The first-born has Asthma. Her grandchildren are alive and well.

ROS:

GENERAL:  Denies pain, elevated body temperature, weight changes, chills, malaise, or fatigue.

CARDIOVASCULAR: Positive for history of high BP. Denies history of palpitations, chest pressure or pain, dyspnea on exertion or at rest, or ankle edema.

RESPIRATORY: Denies cough, bloody sputum, dyspnea, or chest pain.

MUSCULOSKELETAL:  Denies history of fall, muscle pain, or limitations in movement.

PSYCHIATRIC: Denies having visual or auditory hallucinations. Denies having any suicidal thoughts or ideations.

ENDOCRINOLOGIC: Reports low FBS. Positive history of DM.  Denies excessive sweating or heat/cold intolerance.

ALLERGIES: Allergic to penicillin and Lisinopril.

Objective

Physical exam:

Vital Signs: BP 165/90, HR 89, RR 20, Temp 98.1

General: Female patient in her early 60s. The patient is awake, alert, and oriented to person, place, time, and event.

Cardiovascular: No edema or jugular vein distension on inspection. Capillary refill- 3 seconds. Regular heart rate and rhythm. S1 and S2 present on auscultation.

Respiratory: Smooth respirations and the chest rise and fall uniformly on breathing in and out. Lungs clear on auscultation and percussion, and no adventitious sounds are perceived.

Musculoskeletal: The patient exhibits no unusual motor movements and demonstrates no tics.

Diagnostic results:

Chest X-ray- Last Chest X-ray was within normal limits and showed no cardiopulmonary findings.

Basic metabolic panel- Sodium level slightly below the normal range.  Blood glucose, electrolytes, and kidney tests are within the normal range.

CBC and Vitamin D results within the normal range.

Assessment

Differential Diagnoses

Diabetic Hypoglycemia

Hypoglycemia refers to blood glucose below 54 mg/dl. It is mostly detected through self-monitoring blood glucose and continuous glucose monitoring (Kreider, Pereira & Padilla, 2017). Hypoglycemia is a common complication of diabetic treatment with insulin, sulfonylureas, or Glinides and is a limiting factor in the glycemic treatment of diabetes. Therapeutic hyperinsulinemia occurs due to unregulated delivery of endogenous or exogenous insulin therapy into the circulation monitoring (Kreider et al., 2017). Interventions aimed at intensive glycemic control increases the risk of hypoglycemia in diabetic patients.

Diabetic hypoglycemia is a differential diagnosis for this patient based on a history of a low morning FBS below 50mg/dl for several weeks.  The low FBS is probably a complication of the intensive glucose-lowering therapy with Novolog three times a day and Lantus every bedtime.

Uncontrolled Hypertension

Uncontrolled hypertension refers to an average systolic BP greater or equal to 140 mmHg or diastolic BP greater or equal to 90 mm Hg among persons with hypertension on medical treatment (Zhou et al., 2018). Uncontrolled hypertension in hypertensive adults is attributed to increased mortality rates. It is also associated with further complications such as stroke, heart attack, and chronic kidney disease (Zhou et al., 2018). Risk factors for uncontrolled hypertension include obesity and a high sodium diet.

Uncontrolled hypertension is a differential diagnosis based on the patient’s history of elevated blood pressure and high blood pressure of 165/90 mm Hg. The high blood pressure occurs despite the patient being on intensive medication therapy with Chlorthalidone and Amlodipine.

Hyponatremia

Hyponatremia is a serum sodium concentration below 135 mEq/L. It is a common electrolyte abnormality attributed to excess total body water compared to the total body sodium content (Hoorn & Zietse, 2017). In hypovolemic hyponatremia, the total body water decreases more than the decrease in total body sodium. Causes of hypovolemic hyponatremia include diuretics, GI fluid loss, Osmotic dieresis, and Mineralocorticoid deficiency (Hoorn & Zietse, 2017). Patient findings consistent with hyponatremia include a serum sodium level of 134 mEq/L, slightly below the normal range. The hyponatremia can be attributed to diuretic therapy with Chlorthalidone, a thiazide diuretic that impairs urinary dilution.

Plan

Medications

Diabetic Hypoglycemia:  Reduce Lantus dose to 20 units at bedtime.

Uncontrolled Hypertension: Increase Amlodipine to 10 mg PO once daily.

Hyponatremia: Stop Chlorthalidone (Hoorn & Zietse, 2017).

Diagnostic Tests

Hemoglobin A1c (HbA1c) test: A HbA1c test will be ordered to assess the patient’s average glycemic level in the past three months (Kreider et al., 2017). The results will determine if she has achieved a glycemic control of <7.0%. They will also guide the titration of hypoglycemic agents.

Health Education

Lifestyle modification: Patient education will be provided on lifestyle modification by changing dietary habits and increasing physical activity to lower blood pressure and promote glycemic control (Zhou et al., 2018).

Low-sodium diet: The patient will be recommended to have a low-sodium diet to lower and control blood pressure (Zhou et al., 2018).

Medication Adherence: Treatment adherence will be emphasized to promote controlled blood pressure and blood glucose.

Diabetes Self-management education: The patient will be advised to continue with self-monitoring of blood glucose and foot care to prevent diabetes-related complications (Kreider et al., 2017).

Referrals: Referral to an endocrinologist if the blood sugar level is not adequately controlled.

Follow-up: A follow-up visit will be arranged after two weeks to monitor blood pressure and blood glucose level and assess the patient’s response to treatment.

Reflection

The patient in the assignment’s case study presented with comorbid conditions common among patients with chronic illnesses. The patient presents a real picture of what NPs in adult care settings encounter when managing the common chronic conditions. From the assignment, I have learned that medications can cause complications in patients with comorbid diseases. Therefore, it is important that the clinician assesses each drug’s side effects and prescribe a drug after weighing the benefits and risks. Besides, the clinician should evaluate a patient’s current medications to determine if they are the cause of the presenting symptoms.

References

Kreider, K. E., Pereira, K., & Padilla, B. I. (2017). Practical approaches to diagnosing, treating, and preventing hypoglycemia in diabetes. Diabetes Therapy: research, treatment, and education of diabetes and related disorders, 8(6), 1427-1435. https://doi.org/10.1007/s13300-017-0325-9

Hoorn, E. J., & Zietse, R. (2017). Diagnosis and Treatment of Hyponatremia: Compilation of the Guidelines. Journal of the American Society of Nephrology: JASN, 28(5), 1340–1349. https://doi.org/10.1681/ASN.2016101139

Zhou, D., Xi, B., Zhao, M., Wang, L., & Veeranki, S. P. (2018). Uncontrolled hypertension increases the risk of all-cause and cardiovascular disease mortality in US adults: the NHANES III Linked Mortality Study. Scientific reports, 8(1), 9418. https://doi.org/10.1038/s41598-018-27377-2