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Nursing Case Study Analysis On Autoimmune Thyroid Diseases (AITD)-Hyperthyroidism

Question

Task:
Nursing Case Study Scenario:
Sandra Bullock, 39 years of age is seeing a GP, where you work as practice nurse. Over the past 3 weeks, Sandra has noticed significant tiredness, palpitations, and tremor. She has also noted that she is always feeling hot, ‘even when others are feeling cold’. She has lost 5 kg in weight over the past 2 weeks without any effort or exercise. She has also noticed a swelling over the front of her neck. On direct questioning, Sandra has noticed her eyelids are ‘a bit puffy’ and friends have commented that she often looks like she is ‘staring’.

Sandra is a mother of 5 children and lives in suburban Melbourne. Sandra works as a Real-Estate Manager. She has been married to Frank, who is an electrician, for 18 years.

Sandra has been suffering from type 2 Diabetes and rheumatoid arthritis for the past two years. She takes metformin (APO-Metformin XR 500 mg tablet daily) and glipizide (Minidiab 5 mg half a tablet daily) to control her diabetes and Ibuprofen (APO-Ibuprofen 400 mg one table daily) for joint pain. She does not get enough opportunity to exercise and depends on “takeaway” for her lunch and eating snacks and ice cream. She states that she often forgets and does not take her medication regularly. Sandra also smokes 5-6 cigarettes daily.

Her mother and older sister were both diagnosed with T2DM in their early 50’s. Her mother also has Hashimoto thyroiditis.

Sandra is quite “stressed” about her ongoing conditions and the recent development of other symptoms.

The examination findings of Sandra are as following –

  • BMI: 29 m2 /kg
  • Blood Pressure: 140/90 mmHg
  • Pulse rate: 105 beats/min, irregular
  • Respiratory Rate: 22 breaths/minute
  • Temperature: 37.7ºC tympanic
  • SpO2: 97% on RA (Room Air)
  • A smooth, mildly enlarged thyroid gland with a bruit (increased blood flow in the thyroid gland), mild proptosis
  • eyelid retraction bilaterally
  • brisk reflexes, and a fine tremor.

Sandra’s blood tests reveal –

  • Full blood examination (FBE): haemoglobin: 125 g/L (reference range: 120–150 g/L)
  • White cell count: 11.5 X10^9/L (reference range: 4.0–10.0 X 10^9/L)
  • neutrophil: 8.0 X 10^9/L (reference range: 2.0–7.0 X 10^9/L)
  • lymphocytes: 0.8 X 10^9/L (reference range: 1.0–3.0 X 10^9/L)
  • Platelet: 250 X 10^9/L (reference range: 150–400 X 10^9/L)
  • Free T3 = 15 pmol/L (reference range 3.5 – 6.0 pmol/L)
  • Free T4 = 75 pmol/L (reference range 10 – 20 pmol/L
  • TSH = 0.02 (reference range 0.500 – 4.2 IU/L
  • TSH-Receptor antibody (TSH-RAB AB) = positive and significantly elevated.
  • Antithyroid peroxidase (anti-TPO) and antithyroglobulin = negative or low titre

Part 1 Questions
1. What underlying endocrine condition is indicated by Sandra’s blood test, as well as the signs and symptoms (clinical features) she is experiencing? Describe the pathophysiology of the condition. You need to explain the following aspects in this section and link them to Sandra:

1.1 Identify the underlying condition

1.2 Interpret Sandra’s blood test results and clinical features, and link back to Sandra

1.3 Include at least 4 risk factors relevant to Sandra

1.4 Explain the pathophysiology of the specific condition Sandra is suffering from, making links to Sandra throughout

1.5 Explain at least 5 complications of this condition that are relevant to Sandra

Part 2 Questions
Further blood test results reveal that Sandra’s blood glucose level (BGL) is 12.9 mmol/L [3.9-6.1 mmol/L]; HbA1c: 9% [normal<6.5%]

Sandra’s GP referred her to an Endocrinologist. Her conditions, blood test results and medications were reviewed by the specialist. Sandra was advised to stop metformin and prescribed Tab Sitagliptin (Januvia) 50 mg daily in addition to glipizide 5 mg (Minidiab) half a tablet daily. The Endocrinologist also added Tab Carbimazole 5 mg daily for managing her recently developed signs and symptoms, and the related Endocrinological condition.

2.1. Identify 4 risk factors potentially causing Sandra’s high BGL and HbA1c. Discuss how each risk factor affects BGLs and HbA1c.

2.2 Discuss the three medications Sandra is prescribed by the Endocrinologist. Include in your answer the action, complications, relevant side effects and relevant nursing considerations linked to Sandra’s situation.

2.3 Explain five complications that Sandra could experience if her blood glucose level (BGL) and HbA1c remain high.

2.4 Identify and briefly discuss four preventive measures Sandra could use to reduce her risk of developing complications related to T2DM.

Answer

Introduction
This case study involves a patient with pre-existing Type-2 Diabetes (T2DM). She has specific symptoms which indicate that she has an endocrinological disorder. In this case study, the symptoms are studied and analyzed; her blood report was interpreted to reach a diagnosis. Post diagnosis, risk factors involved with her conditions and possible complications are discussed.

Part 1
1.1 Identification of the underlying condition
The patient shows symptoms like puffy, enlarged eyes, hyperthermia, weight loss, tiredness, and swelling on her neck (goiter). Examination by the GP showed she has a faster heart rate and tremors. These symptoms indicate hyperthyroidism or Grave’s disease.

1.2 Interpretation of blood test results and clinical features
Full blood examination (FBE) of the patient reveals that the patient has a 125 g/L blood hemoglobin level which is normal as the normal blood hemoglobin level ranges between 120 -150 g/L. The platelet count is 250 X 109/L, which is also normal as it lies within the normal range of 150 – 400 X 109/L.

The patient has an elevated white blood cell (WBC) count. Her WBC count is 11.5 X 109/L, which is higher than the normal range of 4.0 – 10.0 X 109/L. Individually, the Neutrophil count is higher than normal while the Lymphocyte count is lower than normal. The Neutrophil count of the patient is 8.0 X 109/L, which is higher than the normal range of 2.0 – 7.0 X 109/L. The Lymphocyte count is 0.8 X 109/L where the normal range is 1.0 – 3.0 X 109/L. An elevated WBC count is a sign of AD. As WBCs are responsible for generating immune responses in the body, elevated levels of WBCs indicate that there is an ongoing immunogenic reaction in the body. As the patient is not suffering from any external infections, it can be deduced that the elevated WBC is associated with an autoimmunogenic response, like hyperthyroidism (Yanai, Hakoshima & Katsuyama 2019).

T3 or triiodothyronine is a thyroid hormone derived from the thyroxin hormone T4. T3 is responsible for several physiological functions like growth and development of the body, regulation of body temperature, metabolism, and regulation of heart rate. Increased levels of free T3 and T4 in the body are a sign of hyperthyroidism. Hyperthyroidism refers to increased activity of the thyroid. The FBE of the patient shows very high levels of free T3 and T4. She has 15 pmol/L of free T3 in her blood where the normal range is 3.5 – 6.0 pmol/L and 75 pmol/L free T4 whose normal range in the blood should be 10 – 20 pmol/L. This confirms that the patient has developed hyperthyroidism. She has symptoms like puffy, enlarged eyes, palpitations, and tiredness which are associated with hyperthyroidism (Fantin & Goenmann, 2021).

Hyperthyroidism enhances metabolism which explains her sudden weight loss and her feeling hot even during colder environmental temperatures. Hyperthyroidism is a form of AITD (Trovato, 2020). Therefore, it can also be deduced that the patient is suffering from AITD which is one of the commonest manifestations of an autoimmune disease.

The FBE of the patient also shows that she has low TSH (Thyroid-stimulating hormone) levels in her blood, 0.02 IU/L (normal range is 0.500 – 4.2 IU/L) which are definite signs of hyperthyroidism. The patient also has a positive and elevated level of TSH-Receptor antibody (TSH-RAB AB) and negative antithyroid peroxidase (anti-TPO) and antithyroglobulin. This further confirms that the patient has hyperthyroidism or Grave’s disease (Beck-Peccoz, et al. 2019).

1.3 Risk factors
The risk factors of Grave’s disease associated with this patient include genetic inheritance, smoking, stress, and sex steroids.

Genetic inheritance
AITD is often genetic and thereby a highly inheritable disease. Patients with AITD usually possess genetic factors pertaining to this disease in the HLA complex (HLA DR-3) as well as the T cell regulatory gene (CTLA 4). 79% of occurrences of hyperthyroidism have a genetic basis (Antonelli, et al. 2020). The patient has a family history of AITD as her mother had Hashimoto’s disease. It is a form of AITD where hypothyroidism occurs. 9 out of 10 cases with individuals having AITD-prone genes develop hyperthyroidism over hypothyroidism. Therefore, the patient is at high risk of developing Grave’s disease.

Smoking
Smoking is a major risk factor in AITD. It specifically causes hyperthyroidism (Abbas, 2019), the condition that the patient has. The patient reportedly smokes 5 - 6 cigarettes a day which puts her at high risk for hyperthyroidism. Cigarettes contain certain chemicals that affect the thyroid hormone synthesis pathway and initiates hyperthyroidism.

Stress
Several kinds of stress are linked to hyperthyroidism. It postulated that the induction of immune suppression due to the effects of cortisol on immune cells results in immunogenic hyperactivity which leads to AITD. The patient has a high stress-inducing profession, added to which she is stressed about her health. This puts her at the risk of developing AITD.

Gender
Hyperthyroidism is more common in women than in men, which indicates that the female sex steroids have an effect on the development of the condition (Aboodshaher & Jassim, 2020). Older women are even more likely to develop hyperthyroidism than younger women. The levels of estrogen are possibly not an influencing factor in hyperthyroidism. The female predominance in hyperthyroidism is also presumably skewed due to X-chromosome inactivation. The patient is a woman of age 39, which puts her at moderate risk for hyperthyroidism.

1.4 Pathophysiology of Hyperthyroidism
In hyperthyroidism, the serum levels of T3 or triiodothyronine becomes significantly higher than the serum levels of T4. This probably takes place due to a heightened secretion of T3 in addition to the regular conversion of T4 to T3 which takes place in the peripheral tissues of the body. In some patients, it has been observed that only the serum levels of T3 are elevated while the serum levels of T4 have remained within the normal range. This condition is known as T3 toxicosis. T3 toxicosis takes place during most of the usual disorders associated with hyperthyroidism, like Grave’s disease, autonomous thyroid nodule, and multinodular goiter.

1.5 Complications associated with Hyperthyroidism
Hyperthyroidism may lead to several complications:

Heart problems
Most of the serious complications associated with hyperthyroidism are involved with the heart. These may include tachycardia, or rapid heart rate, atrial fibrillation, a heart-rhythm disorder, and congestive heart failure, a condition that takes place when the heart is incapable of circulating enough blood as required by the body. Atrial fibrillation also increases the risk of stroke. The patient already has type 2 diabetes therefore she must remain careful to avoid heart problems caused by the culmination of her T2DM and HT.

Osteoporosis
Hyperthyroidism is left unchecked can easily lead to a condition of weak and brittle bones, called osteoporosis (Xu, et al, 2020). Excessive T3 in the body as a result of hyperthyroidism interferes with the physiological process of calcium deposition into bones. Without optimum calcium deposition, the bones become brittle as the tensile strength of the bones is derived from the calcium depositions on them. Women develop osteoporosis at older ages, the patient being a woman must remain extra cautious to prevent it.

Eye problems
Patients with Graves' ophthalmopathy often develop eye condition, which includes bulging of the eye, red or swollen eyes, light sensitivity, and blurring or failing vision. Untreated, these can lead to vision loss (Mendonca, et al., 2020). The patient has already developed bulging eyes, she must keep her HT under control to protect her vision.

Inflammated skin
In certain rare cases, patients with Graves' disease also develop a condition called Graves' dermopathy. This condition affects the skin, causing the skin to swell and form redness, often on the lower legs and feet.

Thyrotoxic crisis
Hyperthyroidism generally poses the risk of developing thyrotoxic crisis — a condition characterized by abrupt intensification of HT symptoms, which leads to fever, a rapid heart rate, and delirium.

Part 2
2.1 Risk factors potentially causing high BGL and HbA1c
The patient is already suffering from Type 2 Diabetes Mellitus (T2DM) and is under medication for it. Her blood test results show that the level of sugar and glycated hemoglobin or HbA1c (a substance formed in combination with hemoglobin and sugar in the blood when the blood sugar is high) are higher than normal, indicating that her diabetes is not under control. The patient’s blood glucose level (BGL) is 12.9 mmol/L, which is higher than the normal range of 3.9-6.1 mmol/L, and her blood HbA1c level is 9% when the normal level should be less than 6.5%.

Hereditary
The patient’s mother as well as her sister developed T2DM. T2DM does not show a clear hereditary pattern, but the chances of developing the disease increase with the number of family members suffering from it. Therefore the patient was at high risk of developing the disease herself.

Diet
High sugar, carbohydrates, and fat-containing diet is a major risk factor for developing T2DM. The patient has been known to consume a lot of ‘take-away’ meals and high sugar-containing diets. This caused the advancement of T2DM in the patient.

Lack of Exercise
The patient has a sedentary work-life which involves a lot of stress but does not allow her to be very mobile. She also reported that she does not have the time to exercise regularly. Increased stress along with low exercise is a risk factor in T2DM.

High Blood Cholesterol Levels
High blood cholesterol level is a major risk factor for the development of T2DM. The patient reportedly has a diet and a lifestyle that is supposed to increase her blood cholesterol levels, putting her at the risk of progressing T2DM.

2.2 Medications: Action, Complications, Side effects

Sr. No.

Medication

Action

Side effects

Complications

1

Tab Sitagliptin (Januvia) 50 mg

Sitagliptin selectively inhibits DPP-4, the primary enzyme responsible for degrading the insulin hormone, enabling glucagon-like peptide-1 and glucose-dependent insulinotropic peptide to allow glucose regulation after a meal. (Pieber, et al., 2019)

runny nose,

sore throat

headache

 

fever, loss of appetite, chronic stomach pain, shortness of breath, rapid weight gain, or swelling of feet or ankles,

skin blistering or peeling, joint pain, hives, face swelling, difficulty in swallowing

2

Tab Glipizide 5 mg (Minidiab) 2.5 mg

Glipizide blocks potassium channels among beta cells of the pancreatic islets of Langerhans which leads to the depolarization of these cells resulting in the opening of voltage-gated calcium channels that encourages insulin release from beta cells.

constipation

drowsiness

dizziness

muscle tremors

headache

nausea

diarrhea

yellowing of the skin or eyes,

pain in the upper right part of the stomach, unusual bruising or bleeding

3

Tab Carbimazole

5 mg

Carbimazole decreases the uptake and concentration of inorganic iodine by the thyroid gland. It also reduces the formation of di-iodotyrosine and thyroxine. (Maliakkal, et al., 2021)

diarrhea

dizziness

headache

painful joints

skin rash

thinning hair

Change in gustatory sense, joint pains, jaundice due to liver damage, and negative effects on the bone marrow.

2.3 Complications associated with high BGL and blood HbA1c levels
Complications associated with high blood sugar levels involves:

Kidney failure - Filtration of excessive sugar from the blood over a long period of time leads to kidney failure in individuals that have high BGL over an extended period of time (Beckett, et al., 2018).

Heart problems - High blood sugar often leads to obesity and causes blockages in arteries and veins leading to coronary thrombosis and other heart complications.

Non-healing wounds - High blood sugar encourages bacterial growth which paves the way for severe bacterial infections and bacteremia which results in any wounds taking much longer periods of time to heal.

Hypertension - High blood sugar increases blood density and therefore increases blood pressure (Jee, et al., 2021).

Glaucoma - High blood sugar increases blood pressure which leads to undue pressure on the eyeballs with often leads to glaucoma (Hou, et al., 2021). Glaucoma can lead to complete loss of vision.

2.4 Identification of preventive measures to the risk of developing T2DM related complications
The patient may uptake the following measures to control her high blood sugar levels:

Diet - The patient must take up a low sugar, low carbohydrate, and high fiber diet.

Water intake - The patient must drink an optimum amount of water daily.

Exercise-The patient must exercise daily to burn the calories she intakes through her diet daily.

Medication- The patient must take all the medicines prescribed to her regularly and be cautious about breaking the continuation of her medication.

Conclusion
The patient in the given case study has been suffering from T2DM and came in to consult a GM for her worsening health. Her symptoms included dizziness, tiredness, enlarged eyes, increased heart rate, weight loss. Upon examining her blood report, she was diagnosed with Grave’s disease or hypertension, a form of AITD. The patient also has T2DM and her blood sugar levels are not under control. She was prescribed medication and lifestyle advice to control her blood sugar levels.

References
Abbas, Z., Nasir, A., & Munawar, M. D. (2019). Association of Hyperthyroidism with Tobacco Smoking-A Case-Control Study. Journal of Rawalpindi Medical College, 23(S-1), 34-36.

Aboodshaher, S., & Jassim, B. A. (2020). Histological Study of Hyperthyroidism (Goiter) in Women in Al-Muthanna Province. Indian Journal of Public Health Research & Development, 11(4).

Antonelli, A., Ferrari, S. M., Ragusa, F., Elia, G., Paparo, S. R., Ruffilli, I., ... & Fallahi, P. (2020). Graves’ disease: epidemiology, genetic and environmental risk factors and viruses. Best Practice & Research Clinical Endocrinology & Metabolism, 34(1), 101387.

Beck-Peccoz, P., Giavoli, C., & Lania, A. (2019). A 2019 update on TSH-secreting pituitary adenomas. Journal of endocrinological investigation, 42(12), 1401-1406.

Bequette, B. W., Cameron, F., Buckingham, B. A., Maahs, D. M., & Lum, J. (2018). Overnight hypoglycemia and hyperglycemia mitigation for individuals with type 1 diabetes: how risks can be reduced. Nursing case study IEEE Control Systems Magazine, 38(1), 125-134.

Fantin, E. H., & Goemann, I. M. (2021). Successful Management of Hyperthyroidism With Lithium and Radioiodine in a Patient With Previous Methimazole-Induced Agranulocytosis. Journal of the Endocrine Society, 5(Supplement_1), A958-A958.

Hou, H., Moghimi, S., Baxter, S. L., & Weinreb, R. N. (2021). IS Diabetes Mellitus a Blessing in Disguise for Primary Open Angle Glaucoma?. Journal of glaucoma, 30(1), 1.

Jee, D., Kang, S., Huang, S., & Park, S. (2020). Polygenetic-Risk Scores Related to Crystallin Metabolism Are Associated with Age-Related Cataract Formation and Interact with Hyperglycemia, Hypertension, Western-Style Diet, and Na Intake. Nutrients, 12(11), 3534.

Maliyakkal, A. M., Elhadd, T. A., Naushad, V. A., Shaath, N. M., Farfar, K. L., Ahmed, M. S., & Basheer, S. M. (2021). Carbimazole-Induced Jaundice in Thyrotoxicosis: A Case Report. Cureus, 13(5).

Mendonca, T. M., Pai, S. G., Shetty, S. P., Mukherjee, R., & Vepakommma, T. (2020). An atypical case of unilateral vision loss in thyroid eye disease. Clinical and Experimental Optometry, 103(6), 915-917.

Pieber, T. R., Bode, B., Mertens, A., Cho, Y. M., Christiansen, E., Hertz, C. L., ... & Yavuz, D. (2019). Efficacy and safety of oral semaglutide with flexible dose adjustment versus sitagliptin in type 2 diabetes (PIONEER 7): a multicentre, open-label, randomised, phase 3a trial. The lancet Diabetes & endocrinology, 7(7), 528-539.

Trovato, M. (2020). A historical excursus of diagnostic methods for Hashimoto thyroiditis and Graves’ disease. Gazz. Med. Ital. Arch. Sci. Med, 179, 479-485.

Xu, N., Wang, Y., Xu, Y., Li, L., Chen, J., Mai, X., ... & Chen, R. (2020). Effect of subclinical hyperthyroidism on osteoporosis: A meta-analysis of cohort studies. Endocrine, 69(1), 39-48.

Yanai, H., Hakoshima, M., & Katsuyama, H. (2019). Differences in clinical and laboratory findings among Graves’ Disease, painless thyroiditis and subacute thyroiditis patients with hyperthyroidism. Journal of Endocrinology and Metabolism, 9(3), 37-42.

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