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Pathophysiology Assignment: Systematic Analysis of Sandra’s Medical Condition


Task: Case 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

Consider the above case scenario and prepare a pathophysiology assignmentanswering the below questions:

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.


As per the given case scenario of pathophysiology assignment, Sandra Bullock, 39 years old mother of 5 children who resides in suburban Melbourne has been diagnosed with type 2 diabetes as well as rheumatoid arthritis for the past two years. Sandra also depends on takeaway food and snacks during her office time and being the manager of realestate, she remains stressed and busy. Further, she also smokes 5 cigarettes a day, her eyelids seemed puffy and thus she has been suffering from irregular pulse rate, high BP, brisk reflexes, and enlarged thyroid gland. Moreover, Sandra has also undertaken blood tests as per the advice of the doctor. This study will carry out a systematic analysis of Sandra’s medical condition, the complications faced, and the risk factors by her along with the other preventive measures.

The underlying condition of Sandra

It has been found that since the past three weeks, Sandra has witnessed a significant level of tiredness, tremor, and palpitation in her body despite her prior weaknesses (Taylor et al., 2018). Moreover, she has also been experiencing sudden hotness and cold even though other individuals do not experience it. Her eyes also seemed puffy and all these conditions can be considered to be the alarming symptoms of thyroid. On the other hand, it has been found that as she remained stressed at her workplace, she also forgot to consume her medicines timely which depict her carelessness and a symptom of thyroid. Further, Sandra’s mother is also a patient of Hashimoto thyroiditis. The medical examination of Sandra also indicated a mildly enlarged thyroid gland along with brisk reflexes.

Interpretation of blood test results and clinical features of Sandra
The reports of a full blood examination of Sandra depicted that her haemoglobin is in the correct range, the lymphocytes, platelets, TSH, and the TSH receptor antibody being correct. However, her T3 and T4 are abnormally high, the white cell and the neutrophil being a little high (Lau & Aw, 2020). Moreover, it has been found that Sandra has been witnessing mood swings, sudden changes in the body temperature, as well as changes in metabolism, her blood examination of T3, can be considered to be linked to this. This excessive level of T3 in her blood can be considered to be a case of an overactive thyroid gland or hypothyroidism (de Mul et al., 2021). On the other hand, it has also been found that Sandra has been witnessing lethargy and thus she lost 5 kg weight during the past few weeks without any exercise. As she has been witnessing stress, it is likely to worsen her thyroid condition further and thus she needs to take manage her lifestyle accordingly.

Risk factors relevant to Sandra
The four risk factors that are relevant to Sandra are: Psychological stress: It has been found that as Sandra is the real-estate manager of a company, she has been experiencing a higher level of workload pressure. Moreover, being a mother of five children, Sandra had to manage her household as well as her workplace (Sim, Lethem &Coppini, 2019. Sandra’s husband was an electrician and they were married for 18 years. Further, Sandra often remained stressed about her ongoing changes in the body. Smoking: As Sandra failed to consume her lunch or any food during office hours due to her excessive work pressure, she often smoked cigarettes. With time, Sandra became addicted to cigarettes and thus she became a chain smoker who found it hard to survive without 5-6 cigarettes daily.

Genetics: Sandra’s mother has been suffering from Hashmito thyroiditis and as these autoimmune diseases are hereditary, Sandra needs to undergo different types of autoimmune testing and keep herself healthy. Moreover, it can be said that this is true for Sandra as she has been suffering from rheumatoid arthritis as well as diabetes for the past two years. This can pose risk to Sandra and thus she needs to undergo proper testing (Derevitskii et al., 2020).

Exercise and eating well: Sandra does not consume her meals regularly and on time. She is often found to skip her meals and thus depend on packet snacks or restaurant food. This is likely to lay a worsening effect on her body (Abdi,Zakavi&Azizi, 2020). On the other hand, it has been found that Sandra also failed to undertake any such exercise regularly, and thus this can be regarded to pose a worsening risk to her body.

Pathophysiology of the condition Sandra is suffering from
As Sandra has been diagnosed with hyperthyroidism i.e. the serum T3 is found to increase at a faster rate than T4. This is because of the higher level of secretion of T3 and the transformation of T4 to T3, especially in the peripheral tissues. This toxicosis of T3 occurs mostly in the case of usual disorders causing hyperthyroidism that includes the multinodulargoiter, Graves disease, and the functioning of the thyroid nodule (Boelaert et al., 2020). Further, it has been found that as the T3 level of Sandra is left unnoticed or untreated, she is most likely to develop varied types of abnormalities along with typical hyperthyroidism. All these forms of thyroiditis possess a common hyperthyroid phase that is followed by the hypothyroid phase also.

Complications of these conditions The five complications of hyperthyroidism of Sandra are: Eye: Individuals with Graves ophthalmology or hyperthyroidism often develop eye problems including red, swollen, and puffy eyes. This condition has been witnessed in Sandra and thus it might lead to complete loss of vision if it is left untreated (Taylor et al., 2018). Sandra might also face the problem of blurred as well as double vision in such a situation.

Bone: When hyperthyroidism is left untreated, it is likely to lead to brittle as well as weak bones. This strength of the bones depends on the level of minerals and calcium in the body. However, it can be said that the secretion of higher levels of T3 and T4 also interferes with the ability of the body to incorporate calcium into the body(Sim, Lethem &Coppini, 2019. Sandra needs to keep herself medically checked for avoiding such problems.

Heart: The most serious complications of hyperthyroidism involve the heart. In this case, it might include a rhythm heart disorder known as atrial fibrillation as well as the sudden increase in the heart rate thereby increasing the chance of stroke as well as heart failure (Salih et al., 2017). However, Sandra needs to take complete care of her and thus fulfil the needs of the body to a great extent.

Thyrotoxic crisis: It can be said that hyperthyroidism increases the chance of thyrotoxic crisis leading to intensification of the symptoms along with higher pulse rate, delirium, and fever (Choi et al., 2019). In such a situation, Sandra needs to approach the doctor immediately and seek relevant care.

Red swollen skin: Although this situation can be considered to be rare, individuals suffering from Graves disease are likely to develop Graves dermopathy. As Sandra’s mother has been suffering from Hashmito thyroiditis, Sandra needs to take proper care of her. Individuals suffering from Graves disease tend to witness redness or swelling in the feet and other parts of the body (Sim,Lethem&Coppini, 2019).

Risk factors that cause Sandra’s high BGL and HbA1c
The risk factors that potentially cause Sandra’s high BGL and HbA1c are:

Family history: As Sandra possesses a family history of autoimmune disorder i.e. her mother being a patient of Hashmito thyroiditis and T2DM and her older sister with T2DM, Sandra needs to take proper care of herself. Further, it has been found that Sandra herself has been suffering from type 2 diabetes for the past two years and as she has not been on a regular checkup, her BGL and HbA1c have been affected to a great extent.

Chronic disease: It has been found that Sandra has been suffering from chronic rheumatoid arthritis as well as thyroid along with a family history of blood glucose levels. Further, as she has been not on regular treatment, she is prone to develop more disorders that are likely to affect her BGL and HbA1c (Narindrarangkura et al., 2019).

Severe stress: As Sandra holds a managerial position in a real estate company and also has to look after her five children; it often becomes difficult for her to maintain her work-life balance. Sandra does not care for her health and thus she remains under continuous stress which increases her HbA1c and BGL largely leading to other complications (Lai et al., 2019).

Sleep disorders and effects of medication: Sandra does not get the adequate level of sleep that is required due to her work pressure. Moreover, being a patient withanautoimmune disorder, she needs to be under the continuous monitoring of a doctor, which she does not. Sandra has also not changed the medicines and she is not sure whether the medicines consumed by her are functioning adequately in maintaining the HbA1c and BGL level thereby imbalancing it to a great extent (van Wijngaarden et al., 2017).

Medications prescribed by the endocrinologists to Sandra The actions, complications, relevant side effects, and the nursing considerations of Sitagliptin (Januvia) 50 mg, Glipizide 5 mg (Minidiab), and Tab Carbimazole 5 mg are:




Side effects

Nursing considerations

Sitagliptin (Januvia)

Medicine that is used for the treatment of Type-2 diabetes mellitus. Januvia can be taken alone or in combination with other medicines

·         Pain in the upper stomach

·         Itching

·         Little or stop in urination

·         Swelling, weight gain

·         Shortness of breath(Januvia, 2021)

·         Stuffy nose

·         Headache

·         Low blood sugar

·         Sore throat(Januvia, 2021)

The patients must be encouraged to follow a specific diet, exercise, and medication. It is important to review the signs of hyperglycemia and hypoglycemia (Januvia, 2021).


It is used for the reduction of blood sugar levels or in individuals with high blood sugar that is caused due to type 2 diabetes(Sitagliptin, 2021).

·         Nausea

·         Vomiting

·         Diarrhea

·         Constipation

·         Headache

·         Stomach upset

·         Weight gain (Sitagliptin, 2021)

·         Low blood sugar

·         Digestive problem

It is advised to start this medicine at a low dose and thus increase it gradually upon the advice of the doctor(Sitagliptin, 2021).

Tab Carbimazole

This medicine is used for the reduction of the thyroid function (Carbimazole, 2021).

·         Joint pain

·         Rashes

·         Fever

·         Liver disease

·         Blood and lymphatic disorder

·         Disorder in the endocrine system

·         Immune system disorder

·         Vascular and nervous system disorder

·         Injury, poisoning, and skin rashes(Carbimazole, 2021)

It is the responsibility of the nurse to monitor the TSH level of the patient during and after the consumption of the drug(Carbimazole, 2021).

Complications that are experienced by Sandra when her BGL and HbA1c is high
Kidney Disease: Nephropathy or kidney damage is one of the most vital complications of high BGL and HbA1c. If Sandra does not keep an eye on her kidney, she might require dialysis within few years. Cardiovascular disease: The patients with high HbA1c and BGL are prone to heart attack and hypertension and this is true in the case of Sandra (Boels et al, 2017). Nerve disorder: Loss of sensation as well as tingling in the feet and hands are the most crucial symptoms of uncontrolled BGL and HbA1c. Sandra’s nerves are likely to get damaged and thus she might become more prone to injuries due to a high level of HbA1c (Ghabban et al., 2020).

Blindness: The blood vessels of the eyes are likely to get damaged thereby leading to devastating effects as well as blurred vision. Sandra must keep a check on her blood glucose level to avoid further complications (Chehregosha et al., 2019).

Fatigue: Patients with an excessive supply of glucose in the body experiences fatigue. This is likely to affect the quality of life and thus Sandra needs to take the relevant level of care in this case (Lau & Aw, 2020).

Preventive measures that are to be taken by Sandra
Sandra must be allowed to perform her physical activity regularly for the prevention of type 2 diabetes. This is likely to improve the insulin function and the response in Sandra’s body.

As smoking is found to contribute to serious health disorders, Sandra must be advised to quit smoking immediately and thus lower the risk of type 2 diabetes. It is also important for Sandra to follow a low-carb diet for the prevention of weight loss and thus maintain consistency in the insulin and blood sugar levels.

Sandra must also consume high-fibre diets that are essential for her weight management and gut health (Chehregosha et al., 2019). The insoluble fibres are associated with the reduction in the blood sugar level and thus it can be considered to be effective for lowering type 2 diabetes of Sandra.

Thus, it can be said that Sandra must keep a watch on her food, her lifestyle, and balance between her personal and professional life. A patient like Sandra needs to be under the continuous monitoring of the doctor as she has a family history of autoimmune disorder. Therefore, a balanced diet and proper medical examinational song with consultation are essential for maintaining a healthy lifestyle. ?

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