Adult Week 9 Assignment

A 65-year-old female patient presents with insomnia, nervousness, easy fatigability, palpitations, heat intolerance, and weight loss despite increased appetite. Physical examination revealed findings of tachycardia, lid lag, a slightly enlarged thyroid, hyperreflexia, and fine tremors. These are signs of a condition where excess production of thyroid hormone occurs, known as hyperthyroidism. The ICD-10 code for unspecified thyrotoxicosis without thyrotoxic crisis or storm is E05.90. Taking all the aforementioned into account, the metabolic and cardiovascular symptoms, in conjunction with the physical thyroid findings, the obvious primary diagnosis must be hyperthyroidism.

Differential Diagnoses

Several other potential diagnoses were considered based on the patient’s presentation but were ruled out in favour of hyperthyroidism:

Hyperthyroidism – ICD-10 Code: E05.90

As the principal diagnosis, hyperthyroidism was supported by key symptoms such as weight loss, tachycardia, heat intolerance, and physical examination findings of thyroid enlargement and tremors, as noted by Mathew and Rawla (2023). The constellation of these findings pointed toward an overactive thyroid as the primary cause of the patient’s symptoms.

Generalized Anxiety Disorder (GAD) – ICD-10 Code: F41.1

The patient’s symptoms of insomnia, nervousness, and palpitations may suggest generalized anxiety disorder (GAD), as asserted by Munir and Takov (2022). However, physical signs such as enlargement of the thyroid gland, lid lag, and metabolic symptoms of heat intolerance and weight loss are not typical in generalized anxiety disorder. Though GAD may be presented with tachycardia, tremulousness, palpitations, and heat intolerance-all significant for hyperthyroidism-the absence of any form of recent psychological stressors or any form of emotional disturbance will point against this diagnosis and move it towards the abnormalities observed within the thyroid.

Diabetes Mellitus Type 2 – ICD-10 Code: E11.9

Type 2 diabetes may also be indicated by the patient’s weariness and inadvertent weight loss. However, according to Goyal et al. (2023), the common signs of diabetes, such as impaired vision, polyuria, or polydipsia, do not indicate a high likelihood of developing the condition. Moreover, the symptoms and findings related to the thyroid make the case more thyroid-related rather than metabolic issues like diabetes. If diabetes is still suspected, he can order various blood tests, including those for fasting glucose and HbA1c levels, to rule it out completely.

Management Plan

Pharmacological Treatment

Methimazole (Tapazole)

The initial dose is 10-30 mg once daily to inhibit thyroid hormone synthesis. Monitoring for agranulocytosis, a serious side effect, is necessary (Singh & Correa, 2023).

Propranolol

20-40 mg three times daily to manage tachycardia and tremors. This beta-blocker will control the cardiovascular and adrenergic symptoms associated with hyperthyroidism (Shahrokhi & Gupta, 2023).

Non-Pharmacological Treatment

Long-term management might be radioactive iodine therapy or thyroidectomy when the medication is found to be ineffective. This is particularly relevant given the patient’s age and the risks associated with untreated hyperthyroidism (Samuels, 2021). Dietary recommendations may also be considered, including high-calorie, high-protein intake to combat weight loss and avoiding heat to manage intolerance.

Additional Testing and Referrals

Repeat thyroid function tests (TSH, Free T4) in 4-6 weeks to monitor treatment efficacy. Secondary, referral to an endocrinologist for specialized management and long-term options, including possible surgery or iodine therapy.

Determinants of Health (SDOH), Health Promotion, and Risk Factors

The availability of medical care, the affordability of medications and transportation to and from providers are social determinants of health that could impact compliance with treatment.  The patient should be evaluated for these determinants, and a social worker may need to be involved to ensure the best outcomes. Health promotion should include smoking cessation if appropriate and caffeine reduction to minimize palpitations. Heat intolerance and dietary measures to maintain a proper balance and high-calorie intake should be reviewed.

Patient Education

The patient should be fully enlightened regarding hyperthyroidism and medication adherence. Methimazole requires regular monitoring of thyroid levels and WBC count due to agranulocytosis, as indicated by Singh and Correa (2023). Palpitations and tremors improve with propranolol but should not be self-prescribed. Long-term treatment modalities include radioactive iodine therapy or surgery. This is to help the patient appreciate the possible complications of untreated hyperthyroidism, such as arrhythmias and osteoporosis, in addition to lifestyle modifications, like avoiding caffeine and heat exposure.

Follow-up Instructions

She should be followed up for thyroid function tests in 4-6 weeks to monitor the medication’s efficacy. Also, she should be instructed to return immediately if there is any suspicion of infection, as agranulocytosis is a potential complication of methimazole. If she develops worsening palpitations, confusion, or severe fatigue, she should return sooner to evaluate for complications such as a thyroid storm.

References

Goyal, R., Jialal, I., & Singhal, M. (2023, June 23). Type 2 Diabetes. National Center for Biotechnology Information; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK513253/

Mathew, P., & Rawla, P. (2023, March 19). Hyperthyroidism. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK537053/

Munir, S., & Takov, V. (2022, October 17). Generalized anxiety disorder. National Library of Medicine; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK441870/

Samuels, M. H. (2021, August 9). Hyperthyroidism in Aging (K. R. Feingold, B. Anawalt, A. Boyce, G. Chrousos, K. Dungan, A. Grossman, J. M. Hershman, G. Kaltsas, C. Koch, P. Kopp, M. Korbonits, R. McLachlan, J. E. Morley, M. New, L. Perreault, J. Purnell, R. Rebar, F. Singer, D. L. Trence, & A. Vinik, Eds.). PubMed; MDText.com, Inc. https://www.ncbi.nlm.nih.gov/books/NBK278986/

Shahrokhi, M., & Gupta, V. (2023, May 1). Propranolol. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK557801/

Singh, G., & Correa, R. (2023). Methimazole. PubMed; StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK545223/

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Week 9 case

The patient, a 65 years old female with no significant past medical history, complains of insomnia, nervousness, and fatigue that has progressed over the past few months. She notes occasional palpitations, heat tolerance, and unintentional weight loss despite increased appetite and food intakes. FH is significant for a maternal grandmother who was stated to have “lazy thyroid.” Physical exam reveals tachycardia, lid lag, mildly-enlarged, soft, nontender thyroid with palpable isthmus, hyperreflexia, and fine tremor of hands.

Temp: 99F, Pulse 102 bpm, BP 130/72, Respiration 14 bpm, O2 98% on room air.

Different Diagnoses

1. Hyperthyroidism
2. Generalized anxiety disorder
3. Diabetes mellitus type 2
   

   Adult Week 9 Assignment

Diagnosis

• Hyperthyroidism

1). Primary Diagnosis with ICD-10 Code and Clinical Practice Guideline, 3-5 Differential Diagnoses , and Coding: What were the key clinical presentations in this patient that led you to choose these differentials; then how did you rule them out to reach your primary diagnosis? 15 points

2). Management Plan: Medications ordered (including over the counter) are appropriate, evidence based, written as a complete prescription, and includes appropriate medication education. Nonpharmacological treatment, additional ancillary testing and referrals ordered are appropriate. 20 points

3). Determinants of Health (SDOH), health promotion and risk factors are addressed. 10 points

4). Patient Education: Comprehensive patient education is included related to current health visit. 10 points

5). Follow up instructions are complete and include time to next visit and specific symptoms to prompt a return visit sooner. 5 points

6). Scholarly References and Clinical Practice Guidelines: The assignment includes a minimum of 3 scholarly references that are not older than 5 years. Most recent clinical practice guidelines are included if applicable. 5 points