Instructions for Discussion Replies to 3 DQS
DO NOT JUST REPEAT SAME INFORMATION, DO NOT JUST SAY I AGREE OR THINGS LIKE THAT. YOU NEED TO ADD NEW INFORMATION TO DISCUSSION.
1- Each reply should be at least 200 words.
2- Minimum One Peer reviewed/scholarly reference ( NO MAYO CLINIC/ AHA)
3- APA 6th edition style needs to be followed.
4- Each response should have reference at the end of each reply
5- Reference should be within last 4 years
Q-1
Mrs. Davis comes to the office today with complaints of recent unexplained weight loss. She reports that her weight loss has been sudden and severe with a loss of fifty pounds in three months. She also reports consistent diarrhea that is yellow and liquid. Along with these symptoms, she was prompted to make an appointment due to increasing fatigue, eventually impacting her daily life.
At this point, my differential diagnosis was Irritable bowel syndrome, Inflammatory Bowel Disease, Diarrhea, Malabsorption Syndrome, Dumping Syndrome, and Malnutrition (Pimentel, 2016).
When performing the health interview she reported alopecia, along with increasing fatigue. At this point, I had believed that it strengthened my differential diagnosis as a decrease in inadequate absorption would show signs of malabsorption or a gastrointestinal issue (Pimentel, 2016). However, continuing the health interview, the patient also reported that she had her parathyroid glands removed but did not know why. Upon finding out this information I also wanted to check her thyroid gland before ruling out thyroid involvement.
Upon the physical exam, the patient was noted to have “visible thyroid fullness and diffuse enlargement on palpation” which is a key indicator that the thyroid gland is overworking due to an unknown origin (Pandiyan et al., 2018). At this point, my entire differential has changed to Hyperthyroidism, Diarrhea, Malnutrition, Irritable Bowel Syndrome, and Inflammatory Bowel Disease (Pandiyan et al., 2018).
I decided to investigate this further during the lab portion of the exam, and the results showed a T4 of 22.8 and TSH of 0.01. An elevated T4 and a suppressed TSH are indicative of hyperthyroidism, even with unknown etiology (Pandiyan et al., 2018). Upon combining the subjective and objective data I felt confident that this was the diagnosis.
On a side note, the patient did mention that she was vegan, so even though she was experiencing hyperthyroidism, there was a possibility that her weight loss could have also had other contributing factors such as a poor nutritional diet (Pandiyan et al., 2018). In vegan diets, it is a common occurrence that there is a lack of appropriate nutrition even if eating the appropriate amount of calories per day (Menzel et al., 2020). However, this is easily overcome with better nutritional discipline and eating the right combination of foods that provide a total day’s worth of nutrients (Menzel et al., 2020). I wanted to explore her diet more and assess the appropriateness of the diet but the program is limited.
For the plan, I wanted to involve endocrinology as the patient has had previous endocrine-based surgeries in the past. So a referral would be made to endocrinology for further exploration and additional management of the disease process (Pandiyan et al., 2020). I could also start her on Methimazole 15mg oral daily to begin management of the disease but would defer to endocrine for any additional changes (Pandiyan et al., 2020). I would also like to see her in a month to evaluate the treatment and plan of care for this patient.
References:
Menzel, J., Biemann, R., Longree, A., Isermann, B., Mai, K., Schulze, M. B., Abraham, K., & Weikert, C. (2020). Associations of a vegan diet with inflammatory biomarkers. Scientific Reports, 10(1), 1933. https://doi-org.lopes.idm.oclc.org/10.1038/s41598-020-58875-x
Pandiyan, B., Merrill, S. J., Di Bari, F., Antonelli, A., & Benvenga, S. (2018). A patient-specific treatment model for Graves’ hyperthyroidism. Theoretical Biology and Medical Modelling, 1. https://doi-org.lopes.idm.oclc.org/10.1186/s12976-017-0073-6
Pimentel, M. (2016). Update on Irritable Bowel Syndrome Diagnostics and Therapeutics. Gastroenterology & Hepatology, 12(7), 442–445.
Q-2
Mrs. Green, a 76-year-old patient, has been hospitalized with pneumonia. While rounding on your patient, her neighbors, a younger couple, state that they know she is a diabetic and is not eating correctly. The neighbors, who often take Mrs. Green to the grocery store, state that she buys ice cream and cookies and rarely fixes “proper meals.” They are concerned about her and want the nurse practitioner to notify her family. Upon examination, Mrs. Green is alert, oriented, well-groomed, and appropriate. Her glucose is 200 and she is in no distress. She states, “I like ice cream, I’m old, and I deserve it.” How should you respond?
There are great points that the neighbors make when they express their concern for their neighbors. These concerns come from a place of love and care, not any malice. However, some may feel that people are too invested in their personal lives, and that is okay as well. Every individual has boundaries and it is up to healthcare professionals to explore and educate patients appropriately to allow them to make their own informed decisions.
Diabetic management in elderly patients is dependent on the receptiveness of the individual (Ni et al., 2020). The most that healthcare professionals can do is provide correct information about the benefits of appropriate management and the risks and consequences of improper management (Ni et al., 2020). There are many barriers to any disease process and the patient’s willingness to change their behavior (Bazzano et al., 2019). Some barriers include culture, routines, family experiences, and overall unwillingness to change (Bazzano et al., 2019).
The common saying is that “you can’t help people who do not want to change”.
So honestly, I would first begin the conversation by thanking the neighbors for their concern, and inform them that I will speak to Mrs. Green on the subject. Then once I begin speaking with Mrs. Green I would gauge her understanding of her diabetes and her management of the disease process. I would evaluate her understanding of the benefits and risks of her choices to see if she fully grasps the information. If she does, then I would talk to her about her choices, and if she still has her mind made up, I would tell her I agree with her, and that she should eat ice cream and enjoy it, but to try to limit her intake overall. I would also ask her if she wants to know how well her diabetes is controlled, and if she agrees, I would order a hA1C and go over the results with her.
If she doesn’t want the test, then that is fine too, and if she doesn’t want any additional information, that is fine as well. It is essentially Mrs. Green’s life and her choices, and as long as they’re informed choices, then I would support her in her decisions.
As for the neighbors asking me to inform her family, I would only do so if Mrs. Green agrees and gives me permission to.
We can also apply this scenario to a majority of risky health behaviors in all aspects of human life. Behaviors such as smoking, alcohol intake, drugs, excessive eating, risky sexual behaviors, and many more. If the patient wants to change, they will, if not they won’t. Besides, who would deny an elderly woman ice cream after a bunch of education.
References:
Bazzano, A., Monnette, A., Wharton, M., Price-Haywood, E., Nauman, E., Dominick, P., Glover, C., Hu, G., & Shi, L. (2019). Older patients’ preferences and views related to non-face-to-face diabetes chronic care management: a qualitative study from southeast Louisiana. Patient Preference & Adherence, 13, 901–911. https://doi-org.lopes.idm.oclc.org/10.2147/PPA.S201072
Ni, M., Ayu, D., Wayan, N., & Gusti Putu Suka, A. (2020). Diabetes mellitus control among elderly patients at geriatric polyclinic of Karangasem District Hospital, Bali, Indonesia: a preliminary study. Bali Medical Journal, 9(1), 279–285. https://doi-org.lopes.idm.oclc.org/10.15562/bmj.v9i1.1664
Q-3
Subjective: 50-pound weight loss in three months, having 4 loose “yellow-brown” stools a day, fatigue, dizziness, feeling “jumpy and nervous,” lower leg edema, occasional fast heartbeat, hair loss, shortness of breath, and “lumps on wrists.”
Objective: Her thyroid was noted to be enlarged both visibly and with palpation, she also has a resting tremor. Her gums are pale and she has no oral ulcers. There is no abdominal tenderness on light or deep palpation, or masses palpated. She is slightly tachycardia and has an arrhythmia.
After completing her history and physical, the differentials I came up with were malignancy such as pancreatic or gastric cancer vs hyperthyroid vs inflammatory bowel disease vs celiac.
Laboratory workup included a basic metabolic panel, glucose, C-reactive protein, calcium, and electrolytes, which were normal. Her CBC with differential showed slight normochromic anemia and her TSH, T3, and T4 were abnormal. Because she had an enlarged thyroid and abnormal thyroid levels, the imaging I started with was an ultrasound of her thyroid which was positive for an enlarged thyroid gland. This prompted me to order a thyroid uptake exa, which was high and confirmed my suspicion. Thyroid ultrasound and thyroid radioactive iodine uptake scan have similar sensitivity for the diagnosis of Graves’ disease (Soh & Aw, 2019).
I was confused with this patient’s history. She had her kidney removed “due to having stones,” and had part of her parathyroid removed for unknown reasons. She was on high blood pressure medication, so I thought maybe her hypertension was caused by her hyperparathyroidism and resulted in severe kidney injury requiring its removal? I think it would have been helpful to look up this patient’s chart and see her previous labs or read her previous clinical notes.
There is a broad range of potentially dangerous causes of unintentional weight loss ad diarrhea such as hyperthyroid and malignancy, requiring early diagnosis. This scenario got me thinking about how the symptom of weight loss can easily remain elusive to some patients and be missed in the clinical setting. In addition to clinical judgment, the workup for these types of symptoms needs to be individualized and based on medical history and physical findings, often requiring extensive, costly, and invasive diagnostic tools as to not miss anything (Meurisse et al., 2018). If her symptoms were not related to her thyroid or gastrointestinal in nature, she would be referred to oncology.
Meurisse, M., Gollogly, L., Degauque, C., Fumal, I., Defechereux, T., & Hamoir, E. (2018). Iatrogenic thyrotoxicosis: causal circumstances, pathophysiology, and principles of treatment-review of the literature. World journal of surgery, 24(11), 1377–1385. https://doi.org/10.1007/s002680010228
Soh, S. B., & Aw, T. C. (2019). Laboratory Testing in Thyroid Conditions – Pitfalls and Clinical Utility. Annals of laboratory medicine, 39(1), 3–14. https://doi.org/10.3343/alm.2019.39.1.3
