Thyroid Disorders-Symptoms, Diagnosis, and Differential Analyses

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Patient Information:

Initials: K.V.

Age: 44 years

Sex: Female

Race: Caucasian

CC (chief complaint): Bulging eyes and fatigue

HPI: K.V. is a 44-year-old Caucasian female who presents with bulging eyes and fatigue for the past two weeks. She reports that she started experiencing bulging and painful eyes two weeks ago. She rated the pain five in a score of out of ten. K.V. highlights that she has been experiencing fatigue for the past two weeks despite having enough sleep and rest. The fatigue affects her, so she cannot carry out her daily activities. K.V. realized her neck was swollen that morning, so she visited the hospital. She is also experiencing unintended and uncontrolled weight gain, lowering her self-esteem. K.V. tries to take walks and exercise every evening to lose Weight, but she has continued to gain Weight. The weight gain is conspicuous since most of her clothes no longer fit her. Her plan to exercise is hindered by fatigue. She has not taken any medications to relieve her symptoms.

Current Medications:

Combined oral contraceptive pills O.D.

Paracetamol 1000mg TDS PRN

Allergies: No known food allergy. No known drug allergy.

PMH: K.V. is in good health. She experiences menstrual cramps every month during her menses, which she relieves using paracetamol 1000mg. She has been on combined oral contraceptive pills for the past five years. K.V.’s immunization is current; she received a single dose of Johnson and Johnson’s COVID-19 vaccine on 5/10/2022. She had a spontaneous vaginal delivery in 2003.

Soc Hx: K.V. is an accountant at a supermarket. She lives with her husband and son in a four-bedroom apartment. She is an occasional alcoholic drinker but does not smoke. She maintains a healthy life by eating a balanced diet and walking daily to and from work. She enjoys swimming and cooking new recipes. She lives a disciplined life and obeys traffic rules by always using a safety belt.

Fam Hx: K.V. has an 18-year-old asthmatic son. She is the last born of two children. Her elder brother is a known diabetic. K.V.’s mother died from breast cancer, while her father died from diabetes complications. Her paternal grandparents died of diabetes. Her maternal grandmother died of diabetes, while her maternal grandfather died of prostate cancer.

ROS:

GENERAL: Reports fatigue and weight gain. Denies chills, headaches, night sweats, day sweats, daytime sleepiness, sleep disturbances, or weight loss.

HEENT: Reports bulging, painful eyes, blurred vision, decreased hearing, difficulty swallowing, and hoarse throat. Denies rhinorrhea, double vision, itchy eyes, visual loss, ear fullness, ear noises, ear discharge, and ear infection. Prohibits dry mouth, oral lesions, gum bleeding, or nasal congestion. Her last eye and dental examination were four years ago.

SKIN: Denies rash or itching.

CARDIOVASCULAR: Denies lightheadedness when standing, paroxysmal nocturnal dyspnea, slow wound healing, numbness in extremities, palpitations, arrhythmias, dyspnea, chest pains, or orthopnea.

RESPIRATORY: Denies cough, wheezing, choking when swallowing, chest pains, shortness of breath, holding breath during sleep, difficulty breathing, or sputum production.

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

GENITOURINARY: Denies painful urination, urinary incontinence, dribbling, decreased stream, frequent urination, and blood in the urine. She denies pregnancy. She had her last menstrual period four months ago.

NEUROLOGICAL: Reports changes in memory. Denies memory loss, loss of consciousness, seizures, confusion, difficulty balancing, numbness, tingling sensation, changes in thinking patterns, spells of blindness, or dizziness.

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

HEMATOLOGIC: Denies anemia, bleeding, or bruising.

LYMPHATICS: Reports enlarged nodes. No history of splenectomy.

PSYCHIATRIC: Denies a history of depression or anxiety.

ENDOCRINOLOGIC: Reports cold intolerance. Denies reports of sweating, polyuria, or polydipsia.

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

Physical Exam:

Vital signs: BP 139/80 mmHg, HR-72 bpm, SPO2- 98% on room air, Temp 98.3, RR-18 bpm, Height- 163cm, Weight- 72kgs, BMI 27.1.

General: The patient is cooperative, hygienic, and well-dressed. She appears tired, overweight and has bulging eyes.

HEENT: Clear or nasopharynx, PERRLA, normocephalic head, and blurred vision.

Neck: The neck has a full range of motion in all directions, normal symmetry, standard length, and no palpable lymph nodes.

Respiratory: On palpation, there is no tenderness or palpable mass. On auscultation, normal breathing sounds without wheezing or audible breathing sounds—no chest deformities.

Heart/Peripheral Vascular: On palpation, average heart size and standard heart location. On auscultation, average heart rate, regular rhythm, and no murmurs. Normal extremities.

Abdomen: Denies abdominal pain on palpation. The liver and spleen are of average size, tenderness, and consistency.

Genital/Rectal: The patient declined this exam.

Lymphatic: Swollen lymph nodes.

Musculoskeletal: Symmetric muscle development. Muscle power of 5/5 on extremities. No deformities or swelling on joints.

Neurological: All cranial nerves and deep tendon reflexes are intact.

Psychiatric: Normal mood, memory, awareness of context, and orientation to time and place,

Skin: Her skin tone is appropriate for her ethnicity and dry to the touch.

Diagnostic results:

Pregnancy test: Pregnant women are considered at high risk for most conditions, such as hypothyroidism (Patil et al., 2022). Results were negative for pregnancy.

Thyroid stimulating hormone assay: Recommended to test the level of thyroid stimulating hormone (Pirahanchi et al., 2022). Results show elevated thyroid stimulating hormone of 5.5 mIU/L and normal free hormone levels.

Complete blood count: Recommended to reveal K.V.’s overall health.

Ultrasonography: Recommended to examine the swollen neck.

Differential Diagnoses:

Hypothyroidism: This is an endocrine disorder caused by thyroid hormone deficiency. Patients diagnosed with hypothyroidism usually present with weight gain, cold intolerance, fatigue, hair loss, muscle pain, sleepiness, decreased appetite, depression, constipation, mental impairment, blurred vision, throat hoarseness, reduced perspiration, decreased hearing, and menstrual disturbances (Patil et al., 2022). K.V. presents with weight gain, fatigue, cold intolerance, blurred vision, throat hoarseness, and decreased hearing. She has a BMI of 27.1, which shows she is overweight. A physical examination showed K.V. has a swollen neck and dry skin. K.V.’s symptoms are similar to those of hypothyroidism, making hypothyroidism a differential diagnosis. She has not experienced monthly periods in the last four months, which signifies menstrual disturbances or premenopause, since she is 44 years old. The thyroid stimulating hormone assay is a screening tool for hypothyroidism. K.V.’s results show elevated thyroid stimulating hormone of 5.5 mIU/L and normal free hormones, hence a primary diagnosis of primary hypothyroidism.

Euthyroid sick syndrome: Patients diagnosed with this syndrome have a non-thyroidal illness but abnormal thyroid function tests (Ganesan & Wadud, 2022). K.V.’s tests and clinical presentation show that she has a thyroid illness.

Goiter: K.V. has a swollen neck, as seen in Goiter. Goiter occurs in patients with low thyroid stimulating hormone and excess T4 (Can & Rehman, 2022). K.V.’s results show elevated thyroid stimulating hormone and normal free hormones.

Thyroid lymphoma: Patients diagnosed with thyroid lymphoma present with neck adenopathy (Kesireddy & Lasrado, 2022). K.V. presents with a swollen neck; hence, thyroid lymphoma is a differential diagnosis. Histology tests are negative for lymphoma.

Myxedema crisis: Patients diagnosed with myxedema crisis usually present with signs of severe hypothyroidism (Elshimy et al., 2022). Although K.V.’s symptoms, physical examination, and thyroid-stimulating hormone tests are positive for hypothyroidism, her thyroid-stimulating hormone values are within range for primary hypothyroidism.

This section is not required for the assignments in this course (NURS 6512) but will be needed for future classes.

References

Can, A.S., & Rehman, A. (2022). Goiter. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562161/

Elshimy G, Chippa V, Correa R. Myxedema. [Updated 2022 May 22]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK545193/

Ganesan, K., & Wadud, K. (2021). Euthyroid Sick Syndrome. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK482219/

Kesireddy M, Lasrado S. Thyroid Lymphoma. [Updated 2022 Jun 26]. In: StatPearls [Internet]. Treasure Island (F.L.): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK544282/

Patil, N., Rehman, A., & Jialal, I. (2022). Hypothyroidism. StatPearls Publishing.https://www.ncbi.nlm.nih.gov/books/NBK519536/

Pirahanchi, Y., Toro, F., & Jialal, I. Physiology, Thyroid Stimulating Hormone. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK499850/

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Question

Use the Episodic/Focused SOAP Template and create an episodic/focused note about the patient in the case study you were assigned using the episodic/focused note template provided in the Week 5 resources. Provide evidence from the literature to support diagnostic tests appropriate for each case. List five conditions for the patient’s differential diagnosis and justify why you selected each.
For this Assignment, you must make up information to complete the entire soap note. Please use the soap note exemplar example as a guide. I think it is essential to document a detailed HEENT exam and HEENT ROS for this Assignment. Writing a heart and lung exam on each patient is also necessary. For the Subjective Data (document constitutional/general ROS) on all patients and Psych. Please use your clinical guide to documentation textbook as a guide as needed for documentation purposes.

Thyroid Disorders-Symptoms, Diagnosis, and Differential Analyses

Case study
Kali, a 44-year-old female, is in the office for a complete physical examination. She complains of proptosis and feeling fatigued. Her TSH levels are elevated, she has hyperlipidemia, her neck appears swollen, and she is overweight.

Case Study Assignment: Assessing the Head, Eyes, Ears, Nose, and Throat
Nurses conducting assessments of the ears, nose, and throat must be able to identify the minor differences between life-threatening conditions and benign ones. For instance, if a patient with a sore throat and a runny nose also has inflamed lymph nodes, the inflammation is probably due to the pathogen causing the sore throat rather than a case of throat cancer. With this knowledge and a sufficient patient health history, a nurse would not need to escalate the assessment to a biopsy or an MRI of the lymph nodes but would probably perform a simple strep test.
Most non-critical care settings have minor ear, nose, and throat conditions. However, subtle symptoms can sometimes escalate into life-threatening conditions that require prompt assessment and treatment.
In this Case Study Assignment, you consider case studies of abnormal findings from patients in a clinical setting. You determine what history should be collected from the patients, what physical exams and diagnostic tests should be conducted, and formulate a differential diagnosis with several possible conditions.
To Prepare

• By Day 1 of this week, you will be assigned to a specific case study for this Assignment. Please see the “Course Announcements” section of the classroom for your Assignment from your Instructor.
• Also, your Case Study Assignment should be in the Episodic/Focused SOAP Note format rather than the traditional narrative style format. Refer to Chapter 2 of the Sullivan text and the Episodic/Focused SOAP Template in the Week 5 Learning Resources for guidance. Remember that all Episodic/Focused SOAP Notes have specific data included in every patient case.

About the case study, you were assigned:
• Review this week’s Learning Resources and consider the insights they provide.
• Consider what history would be necessary to collect from the patient.
• Consider what physical exams and diagnostic tests would be appropriate to gather more information about the patient’s condition. How would the results be used to make a diagnosis?
• Identify at least five possible conditions that may be considered in a differential diagnosis for the patient.