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Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

NURS 6512 Assignment 1: Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat

Patient Information:

Initials, Age, Sex, Race

CC: proptosis and fatigue

HPI: K.N is a 44-year old female who presents for a complete physical examination. She complains of proptosis and feeling fatigued. She reports that her eyes began bulging three weeks ago, and that it affects her vision. She reports that she began experiencing fatigue two weeks ago and she has not been able to complete her daily activities. She also reports a swollen neck and has hyperlipidemia for which she takes atorvastatin. She reports weight gain but denies fever, headache, vomiting or diarrhea.

Current Medications: atorvastatin 20 mg once daily

Allergies: NKDA

PMHx: immunizations are up to date. Received tetanus vaccine 5/10/2021. History of hyperlipidemia

Soc Hx: K.N is an elementary school teacher at a local school. She lives with her husband and two children. Her hobbies include reading novels and traveling. She admits to drinking once in a while. Denies tobacco or illicit drug use.

Fam Hx: Mother: history of hyperlipidemia, type 2 diabetes. Father:hypertension. Her brother is in good health.

ROS:

GENERAL:  Reports weight gain and fatigue. Denies fever or chills.

HEENT:  Eyes: Reports proptosis. Ears, Nose, Throat:  Denies hearing loss, sneezing, congestion, runny nose or sore throat.

SKIN:  Denies rash or itching.

CARDIOVASCULAR:  Denies chest pain, chest pressure or chest discomfort. No palpitations or edema.

RESPIRATORY:  Denies shortness of breath, cough or sputum.

GASTROINTESTINAL:  Denies anorexia, nausea, vomiting or diarrhea. Denies abdominal pain.

GENITOURINARY:  Denies pain on urination.

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NEUROLOGICAL:  Denies headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  Denies muscle, back pain, joint pain or stiffness.

HEMATOLOGIC:  Denies anemia, bleeding or bruising.

LYMPHATICS:  Reports enlarged nodes in the neck. No history of splenectomy.

PSYCHIATRIC:  Denies history of depression or anxiety.

ENDOCRINOLOGIC:  Denies sweating, cold or heat intolerance. Denies polyuria or polydipsia.

ALLERGIES:  Denies history of asthma, hives, eczema or rhinitis.

O.

Physical exam:

Vital signs: H 5’5”, W 88 kg, RR 16 HR 89 BP 128/78

HEENT: Bulging eyes noted. Intact ears with good reflex. Enlarged thyroid noted.

Diagnostic results:

TSH test, thyroid antibody test, hemoglobin A1C test results pending

A.

Differential Diagnoses 

  1. Graves’ disease: This is an immune system illness that leads to the excess production of thyroid hormones (hyperthyroidism). Even though hyperthyroidism may be caused by a variety of different conditions, Graves’ disease is the most frequent. Graves’ disease manifests itself in a variety of ways because thyroid hormones influence so many different body systems. Protrusion of the eyes, excessive perspiration, fatigue, rapid heart rate, irregular heart rate, goiter, and weight loss are all possible symptoms (Wiersinga, 2019). The major therapeutic objectives are to lower the quantity of thyroid hormones produced by the body and to reduce the severity of the associated symptoms.
  2. Hyperthyroidism: When the thyroid gland generates an excessive amount of the hormone thyroxine, this is referred to as hyperthyroidism (overactive thyroid). There are a variety of illnesses that may induce hyperthyroidism, including Graves’ disease, Plummer’s disease, and thyroiditis, among others. It is a condition in which the body’s metabolism is accelerated, resulting in unintentional weight loss as well as a fast or irregular heartbeat. A doctor may have difficulty diagnosing hyperthyroidism since the symptoms might be similar to those of other health disorders. It may also induce a broad range of indications and symptoms, including unintentional weight loss, rapid heartbeat, sweating, tremor, fatigue, and heightened heat sensitivity, to name a few examples. People over the age of 65 are more prone than younger people to have either no signs and symptoms at all or just modest ones such as an elevated heart rate, heat intolerance, and a propensity to become tired while doing everyday tasks (Taylor et al., 2018). Hyperthyroidism may be treated in a variety of ways. The synthesis of thyroid hormones is slowed by the use of anti-thyroid medicines and radioactive iodine administered by doctors. In certain cases, surgery to remove all or part of the thyroid gland is required for hyperthyroidism management. Although hyperthyroidism may be life-threatening if left untreated, the majority of persons who are identified and treated for hyperthyroidism do well.
  3. Thyroid hormone resistance: An uncommon genetic disorder known as thyroid hormone resistance occurs when some body tissues do not react appropriately to thyroid hormones generated by the thyroid gland. This condition may be accompanied by no symptoms or by characteristics of both an overactive and an underactive thyroid gland. Due to the fact that thyroid hormone does not properly shut down the pituitary gland (which regulates hormone synthesis from the thyroid gland), the thyroid hormone level is increased in the blood (Singh & Yen, 2017). Excessive production of thyroid hormone might result in the enlargement of the thyroid gland (goiter). When exposed to high doses of thyroid hormones, peripheral tissues may become resistant or retain sensitivity, resulting in characteristics of both an underactive and an overactive thyroid.

 

 

References

Singh, B. K., & Yen, P. M. (2017). A clinician’s guide to understanding resistance to thyroid hormone due to receptor mutations in the TRα and TRβ isoforms. Clinical diabetes and endocrinology, 3(1), 1-11. https://doi.org/10.1186/s40842-017-0046-z

Taylor, P. N., Albrecht, D., Scholz, A., Gutierrez-Buey, G., Lazarus, J. H., Dayan, C. M., & Okosieme, O. E. (2018). Global epidemiology of hyperthyroidism and hypothyroidism. Nature Reviews Endocrinology, 14(5), 301-316. https://doi.org/10.1038/nrendo.2018.18

Wiersinga, W. M. (2019). Graves’ disease: Can it be cured? Endocrinology and Metabolism, 34(1), 29. https://doi.org/10.3803/enm.2019.34.1.29

 

 

CC: “My eyes are bulging and I feel fatigued.”

HPI:

Kali is a 44-year-old White woman on physical exam with primary symptoms of protruding eyes and fatigue. The symptoms began about four months ago, and the fatigue has worsened. The fatigue has no aggravating factors, but resting alleviated it to some degree. The symptoms have significantly affected her occupational functioning since she always feels tired.

Current Medications: Atorvastatin 40 mg OD for hyperlipidemia.

Allergies: No allergies.

PMHx: Vaccination is current. The last TT was four years ago, and she received a FLU shot 5 months ago. Positive history of dyslipidemia diagnosed 12 months ago. No history of surgery.

Soc Hx: Kali is a corporate secretary working in an insurance firm. She is a Certified Professional Secretary and has a Diploma in Business Administration. She is married and has two children, 20 and 17 years old. Her hobbies include baking and reading magazines. She takes 3-4 beers on weekends but denies smoking or using illicit substances. Her souse and sister are the support system.

Fam Hx: The grandmother had Diabetes, and the grandfather succumbed to Lung cancer. Her elder sister also has Diabetes. The children are well.

ROS:

Vital signs: BP- 132/84; HR-94; RR- 20; Temp- 98.4F

Wt-188 lbs; Ht-5’6; BMI- 30.3

GENERAL:  Reports fatigue and weight gain. Denies fever/chills.

HEENT:  Eyes: Positive for bulged eyes. Negative for other eye symptoms. Ears: Denies ear symptoms. Nose: Negative for sneezing, nose bleed, nasal discharge. Throat: Negative for sore throat or swallowing difficulties.

SKIN:  Negative for skin symptoms.

CARDIOVASCULAR: Negative for edema, neck vein distension, chest pain, palpitations, or SOB.

RESPIRATORY:  Negative for respiratory symptoms.

GASTROINTESTINAL: Denies abdominal symptoms.

GENITOURINARY: Denies genitourinary symptoms.

NEUROLOGICAL: Positive for fatigue. Negative for headaches, dizziness, muscle weakness, syncope, or burning sensations.

MUSCULOSKELETAL: Denies musculoskeletal symptoms.

HEMATOLOGIC:  Denies hematologic symptoms.

LYMPHATICS: Denies lymphatic symptoms.

PSYCHIATRIC:  Negative for mood symptoms.

ENDOCRINOLOGIC: Denies endocrine symptoms.

ALLERGIES: Negative for allergic symptoms.

O.

Physical exam:

GENERAL: Female patient in her early 40s. She appears overweight, alert, and oriented. Her speech is clear and goal-directed, and she maintains eye contact throughout the session.

HEENT: Head: Atraumatic and normocephalic. Eyes: Bulging eyes bilaterally, lid lag, lid retraction, PERRLA. Ears: Tympanic membranes are intact and shiny, with minimal pus. Nose: Moist mucous membranes, patent nostrils. Throat: Tongue is midline, and tonsillar glands are non-inflamed.

NECK: Swollen; The thyroid gland is smooth and; thyroid bruits present.

CARDIOVASCULAR: Regular heart rate and rhythm. Audible S1 and S2 with no murmurs.

RESPIRATORY: Uniform chest rise and fall; smooth respirations; Chest is clear.

Diagnostic results:

TSH levels- elevated.

A.

Differential Diagnoses

Graves disease: Grave’s disease is the most prevalent form of hyperthyroidism. The typical clinical features of Grave’s disease are increased levels of Thyroxine (T4) and enlargement of the thyroid gland. Ophthalmopathy is the hallmark of Graves disease and manifests with eye redness, swelling, upper eyelid retraction, lid lag, conjunctivitis, and bulging eyes Davies et al., 2020). Clinical symptoms include fatigue, general body weakness, sweating, warm, moist, fine skin, eye pain, photophobia, protruding eyes, double vision, heat intolerance, and weight loss despite increased appetite (Davies et al., 2020). Physical exam of the neck reveals a diffusely enlarged and smooth thyroid gland. Graves disease is a presumptive diagnosis based on positive symptoms of bulging eyes, fatigue, elevated TSH levels, thyroid bruits, and diffusely enlarged and smooth thyroid gland.

Subacute thyroiditis: Subacute thyroiditis is diagnosed based on a history of neck tenderness, respiratory tract infection, increased sedimentation rate, and inadequate or absent radioactive iodine consumption. It has a self-limited course. Local thyroid symptoms include dysphagia, pain over the thyroid area (gradual or sudden onset), and hoarseness (Stasiak & Lewiński, 2021). Constitutional clinical symptoms include fever, anorexia, malaise, fatigue, and myalgia. In stage three of the disease, TSH levels are usually elevated. Subacute thyroiditis is a differential diagnosis based on positive symptoms of swollen neck, fatigue, and elevated TSH levels.

Hashimoto Thyroiditis: Hashimoto Thyroiditis occurs due to the damage of thyroid cells by immune processes mediated by cells and antibodies. It is the most common cause of hypothyroidism. Symptoms include fatigue, energy loss, constipation, dry skin, weight gain, and bulging/protruding eyes (Ragusa et al., 2019). In addition, the TSH levels are invariably elevated. Positve clinical features of fatigue, bulging eyes, weight gain, and increased TSH levels support Hashimoto Thyroiditis as a differential diagnosis.

Goiter: Goiter presents with a distended thyroid gland (diffuse or nodular). The thyroid gland causes compresses adjacent organs causing shortness of breath, painful swallowing, stridor, nd voice hoarseness (Ragusa et al., 2019). The findings of a distended thyroid gland mae==ke Goiter a possible diagnosis.

Exophthalmos: Exophthalmos is an abnormal bulging of the eyeball. It is characterized by pupillary abnormalities. Patients also report pain, double vision, pulsation, change in effect or size with position, and disturbance in visual acuity (Topilow et al., 2020). Exophthalmos is a likely diagnosis owing to protruding eyes.

 

References

Davies, T. F., Andersen, S., Latif, R., Nagayama, Y., Barbesino, G., Brito, M., Eckstein, A. K., Stagnaro-Green, A., & Kahaly, G. J. (2020). Graves’ disease. Nature reviews. Disease primers6(1), 52. https://doi.org/10.1038/s41572-020-0184-y

Ragusa, F., Fallahi, P., Elia, G., Gonnella, D., Paparo, S. R., Giusti, C., Churilov, L. P., Ferrari, S. M., & Antonelli, A. (2019). Hashimotos’ thyroiditis: Epidemiology, pathogenesis, clinic, and therapy. Best practice & research. Clinical endocrinology & metabolism33(6), 101367. https://doi.org/10.1016/j.beem.2019.101367

Stasiak, M., & Lewiński, A. (2021). New aspects in the pathogenesis and management of subacute thyroiditis. Reviews in Endocrine and Metabolic Disorders, 1-13. https://doi.org/10.1007/s11154-021-09648-y

Topilow, N. J., Tran, A. Q., Koo, E. B., & Alabiad, C. R. (2020). Etiologies of Proptosis: A review. Internal medicine review (Washington, D.C.: Online)6(3), 10.18103/imr.v6i3.852. https://doi.org/10.18103/imr.v6i3.852