NR511 Week 6 Case Study Part 2 K. Thompson-complete 2022

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NR511 Week 6 Case Study Part 2 K. Thompson-complete 2022 Dr. Charles and class, Following is my findings in part 2 of our case study for week 6. Primary Diagnosis My primary diagnosis ... for this patient is hypothyroidism (low thyroid) with an ICD-10 of E03.9 (“ICD10Data.com,” 2018). As discussed in part 1 of the case study, the patient has some classic symptoms of cold intolerance, lethargy, tiredness, diastolic HTN, low basal metabolic rate (shown by a weight gain of 5lbs in 6 months), muscle cramps, constipation, generalized dry skin, and course hair (Jonklaas et al., 2014). Now that the labs are resulted, we can say with confidence that the primary differential is hypothyroidism, since the TSH is elevated (Samuels et al., 2017) and the free T4 is low (Fallahi, Ferrari, Ruffilli, & Antonelli, 2016). Treatment Plan Medication Levothyroxine 25mcg Disp #30 Sig: 1 tablet daily, take 1 hour before breakfast or 3 hours after evening meal RF: 1 (Jonklaas et al., 2014). Further Tests I did not initially order a CBC in part 1 of my case study assignment, though I did want to do it; I simply could not find the appropriate EBP at the time to back it up. I have since found better clinical guidelines, so for further testing, I would do a CBC because I want to know what the hemoglobin is to rule out any anemia, which hypothyroidism can be associated with CONTINUED....... [Show More]

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