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NR 511 Week 6 Clinical Case Study Part Two Discussion
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Week 6: Clinical Case Study Part Two Discussion44 unread replies.2828 replies.
Now, assume that you sent your patient for labs and she returns the following day, as instructed,
to review the results.
CBC with differential
WBC 8.6 x10E3/uL
RBC 4.44 x 10E6/uL
Hemoglobin 14.0 g/dL
Hematocrit 41.2%
MCV 93fL
MCH 31.5 pg
MCHC 34.0 g/dL
RDW 13%
Platelet 241 x 10E3/uL
Neutrophils % 67%
Lymphocytes % 22%
Monocytes % 8%
Eosinophils % 3%
Basophils % 0%
Absolute Neutrophils 5.7 x 10E3/uL
Absolute Lymphocytes 1.9 x 10E3/uL
, Absolute Monocytes 0.7 x 10E3/uL
Eosinophils Absolute 0.3 x 10E3/uL
Basophile Absolute 0.0 x 10E3/uL
Immature Grans % 0%
Absolute Immature Grans 0.0 x 10E3/uL
TSH with Reflex to FT4
TSH 6.770 uIU/mL
FT4 0.62 ng/dL
PHQ-9 Depression Score=10 (previous was 5 at last visit 6 months ago)
1. What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your
decision for your diagnosis with pertinent positives and negatives from the case)
2. Identify the corresponding ICD-10 code.
3. Provide a treatment plan for this patient's primary diagnosis which includes:
o Medication*
o Any additional testing necessary for this particular diagnosis*
o Patient education*
o Referral
4. Provide an active problem list for this patient based on the information given in the case.
5. Are there any changes that you would make to the patient's overall plan at this time? Must
provide an evidence-based medicine (EBM) argument to support any treatments or testing decisions.
6. Provide an appropriate follow-up plan (include any additional testing that you feel is necessary
and include an EBM argument).
*If part of the plan does not warrant an action, you must explain why. ALL medication and
testing decisions (or decisions not to treat with medication or additional testing) MUST be
supported with an EBM argument. Over-the-counter (OTC) and RXs must be written in full as if
handing a script to the patient in the office.
Participation Guidelines
, Enters initial post to part one by 11:59 p.m. MT on Tuesday; initial post to part two by 11:59
p.m. MT on Thursday; responds substantively to at least one topic-related post of a peer
including evidence from appropriate sources in parts one and two, AND all direct faculty
questions in parts one and two by Sunday, 11:59 p.m. MT.
**To see view the grading criteria/rubric, please click on the 3 dots in the box at the end of the
solid gray bar above the discussion board title and then Show Rubric.
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Collapse SubdiscussionJaemee Nguyen
Jaemee Nguyen
Aug 13, 2019Aug 13 at 10:19pm
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Dr.Feehan and class,
Week 6: Clinical Case Study Part Two Discussion
Primary diagnosis and ICD-10
The U.S. Preventative Task Force (2015) also supports diagnosis of hypothyroidism based on
elevated TSH and low T4 levels with or without clinical symptoms such as fatigue, weight gain or
constipation. Pertinent positive findings: Generalized fatigue and weakness, weight gain as well
as brittle nails and coarse hair, intolerance to cold, decreased DTRs in knees and ankles (+1),
muscle cramping in calves, increased TSH level of 6.770 µIU/mL (normal range 0.5 – 4.70
µIU/mL), decreased FT4 level of 0.62 ng/dL (normal range 0.8 – 1.8 ng/dL). Review of the
patient’s lab values indicates that her TSH is elevated and her FT4 is low which supports my
primary diagnosis or of hypothyroidism with a corresponding ICD 10 code of E03.9.
Treatment Plan
While the patient’s lab values provide a diagnosis of hypothyroidism, there are conflicting
recommendations regarding when medical management should begin. The most recent clinical
guidelines provided by the American Association of Clinical Endocrinologists and the American
Thyroid Association recommends medical therapy using levothyroxine when the patient’s TSH is
greater that 10mIU/L. This same guideline states that the benefit in treating patients with a TSH
between 4.5 to 10mIU/L is not clear. The decision to treat patients that have hypothyroidism as
diagnosed by a TSH above 4.12mIU/L, but have a TSH less than 10mIU/L should be
individualized based on the degree of symptoms, and risk of heart disease. With this in mind,
consideration of the patient’s symptoms of ongoing fatigue that is interfering with her functional
ability to work, increased depression symptoms, weight gain, constipation and cold intolerance
supports the decision to start medical therapy at this time.
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