NR 511 Week PART 2 CASE STUDY 2023 100% CORRECT

What is your primary diagnosis for this patient as the cause for the CC of fatigue? Based on the patient’s lab results, the primary diagnosis for this patient as the cause for the chief complaint of fatigue would be hypothyroidism. The CBC with differential results were normal and there were no signs of infection or anemia noted. The patient’s PHQ-9 Depression Score =10 which is up from her previous score of 5 six months ago. A thyroid stimulating hormone level 4.0/mU/L with a low T4 level indicates hypothyroidism (Dunn & Turner 2016). The patient’s TSH level is noted at 6.770 uIU/mL and FT4 level is 0.62 ng/dL which is indicative of hypothyroidism. The thyroid gland is a pertinent in manufacturing the thyroid hormones triiodothyronine which is T3 and thyroxine which is T4 and is needed in maintaining the body’s metabolism, growth, develop and energy ((Dunn & Turner 2016).).  Pertinent positive findings: constipation, weight gain, dry skin, coarse hair, cold intolerance, muscle weakness, impaired memory, worsening depression, and fatigue  Pertinent negative findings: puffy face, enlarged thyroid, hoarseness, muscle aches, stiffness, pain, irregular menstrual periods, tenderness, thinning hair, bradycardia, hair thinning or loss, vague aches, and pain Identify the corresponding ICD-10 code. Hypothyroidism E03.9 Provide a treatment plan for this patient’s primary diagnosis which includes: Medication The treatment and management of hypothyroidism includes prescribing levothyroxine (Synthroid) daily. Levothyroxine aids in the management and decreasing or “reversing the signs and symptoms” associated with hypothyroidism. Levothyroxine is an artificial material that mimics the T4 hormone. As stated by Duntas, L. & Jonklaas, J. (2019), “Levothyroxine (LT 4) has been considered the standard of care for treatment of hypothyroidism for many years. This treatment is efficacious when administered orally, has a long serum half-life that permits daily administration, and results in resolution of the signs and symptoms of hypothyroidism in most patients (Duntas, L. & Jonklaas, J. 2019).). Treatment with levothyroxine is life-long. Initial dosages for treatment of hypothyroidism is based off the patient’s other medical conditions, age, and weight. Initial doses for primary hypothyroidism are levothyroxine: 1.6 mcg / kg orally once daily and adjustments or an increase in dosages of 12.5 to 25 mcg every 4 to 6 weeks until the patients TSH becomes normal. The patient’s current weight is 81kg x 1.6 mcg=130 mcg of po levothyroxine daily. Dosing for this patient would be 125mcg (.0125mg) would be the daily recommended dose for this patient (Duntas, L. & Jonklaas, J.2019). The prescription would be written as: Levothyroxine (Synthroid) 125mcg tablet for hypothyroidism