1. What is the most likely etiological factor for Mrs. Baksh’s primary hypothyroidism? Explain in detail the pathophysiology of primary hypothyroidism using the complex feedback mechanism. According to the American Thyroid Association, the three most common causes to hypothyroidism are: the surgical removal of the thyroid gland, radiation treatment and the body attacking thyroid tissue as a result of autoimmune diseases like Hashimoto’s thyroiditis (American Thyroid Association, 2014). In Mrs. Baksh’s case, the patient did not have any past medical history of thyroidal surgery or radiation treatment.
Therefore the most likely etiological factor contributing to her primary hypothyroidism is autoimmune disease. In addition, due to the physical presence of a goiter (a visible enlarged, palpable, firm and non-nodular swelling of the thyroid gland), it further supports the conclusion that autoimmune disorder is most likely reason (LeMone et al. , 2011). The pathophysiology of hypothyroidism can be explained in the following diagram: 2. Provide a detail explanation for each of abnormal manifestations noted on physical examination The thyroid gland produces two hormones – triiodothyronine (T3) and hyroxine (T4), which has several functions.
It increases the rate of energy released from carbohydrates, increases the rates of protein synthesis, accelerates growth and stimulates activities of the nervous system (Shier et al. , 2000). Every cell within the body depends on thyroid hormones, as T3 and T4 controls metabolism by converting oxygen and calories into energy and heat (LeMone et al. , 2011). Manifestation Explanation Palpable and enlarged thyroid gland (firm and not nodular) Low TH levels stimulates the pituitary gland to secrete thyroid stimulating hormone (TSH), which increases TH production from he thyroid gland and causes growth of the thyroid gland.
Hair loss Low TH levels affect the reproduction of hair folic cell, which leads to hair loss due to reduced metabolic rate. Bradycardia Low TH levels in the blood stream decreases the rate of energy release and slows down the cardiac contraction and conduction. Generalized weakness and fatigue Low TH levels reduces the energy release rate, resulting in insufficient energy available for muscular contraction Weight gain Low TH levels slows down the metabolic and energy release rate so that less waste of human body is excreted.
Puffy face with peri-orbital edema Infiltration f mucopolysaccharides, hyaluronic acid (products of metabolic disorder) and chondroitin sulfate, pulls fluid into the interstitial space by osmosis leading to facial puffiness and periorbital swelling. Slow speech and a hoarse and husky voice Low TH levels reduce stimulation of the nervous system and affects movement of speech organ due to decreased energy release rate. Constipation Low TH levels reduce the stimulation of CNS and PNS, causing decrease Gl motility and peristaltic activity due to insufficient energy availability.
Pale cool dry skin Low TH levels decreases cellular metabolism and therefore decreases he production of water molecules within cells as well as heat (generated as a result of catabolism). This makes the skin dry & cool. 3. What physical assessment finding(s) in Mrs. Baksh indicates a chronic untreated hypothyroid state? Provide a detail explanation of your answer. Hypothyroidism can cause complications to the nervous system, in which stimulation to the CNS is reduced. Areas the brain, such as the hippocampus, needs TH because it assists to maintain its functionality (Cooke et al. , 2014).
Hypothyroidism would evidently affect the person’s memory, because the hippocampus controls memory, synaptic lasticity and neurogenesis (Cooke et al. , 2014). Since synaptic plasticity and neurogenesis is decreased, a patient with hypothyroidism would have decrease CNS stimulation, which would cause the slow speech and hoarse voice we observe with the patient. The fact that the patient is experiencing constipation could be an indication that the patient has a chronic condition, since constipation occurs as a result of the body slowing down due to lack of energy production caused by low TH (LeMone et al. 2011).
If cells do not have the sufficient energy needed for normal functioning, body processes, such as Gl motility and peristalsis, would slow down (LeMone et al. , 2011). Patients that have hypothyroidism may experience alveolar hypoventilation, which may cause them to have dyspnea (Johnson, 2016). Diaphragmatic dysfunction may cause mild weakness or paralysis of the diaphragm (Martinez et al. , 1989). This pulmonary dysfunction may be exhibited by a fatiguing breathing pattern (dyspnea) (Martinez et al. , 1989). T3 and T4 aid in regulating cellular metabolism.
Because the thyroid gland is secreting insufficient amounts of TH, the body is storing carbohydrates and fats into body tissues at a higher rate han it is being metabolized and used for energy (VanMeter et al. , 2014). This accounts for the patient experiencing weight gain. Furthermore, TH regulates hair growth and skin integrity by promoting their growth (VanMeter et al. , 2014). With insufficient TH, the skin would be deficient in oxygen and protein due to the lack of energy available and mobilization of proteins (Forman, 1955).
Another contributing factor is hyperkeratosis, which would add to the patient’s scaly, drying skin (Forman, 1955). This would cause the dryness in the hair and skin to be more prominent. This fortifies the assessment findings of the patient xperiencing alopecia, a condition in which hair becomes brittle and eventually falls off (LeMone et al. , 2011). The firm non- palpable thyroid is due to the insufficient release of TH. To compensate for the low TH levels, the thyroid attempts to produce more TH levels, causing it to enlarge and become firm (LeMone et al. 2011). The enlarged tongue may be caused enlarged lymph nodes found below the tongue. Edema may cause the flow of lymph to be blocked or decreased, which consequently causes an accumulation of fluid to a specific area, such as the tongue (LeMone et al. , 2011).
4. What life threatening complication can Mrs. Baksh develop from long standing untreated hypothyroidism? Identify and explain key manifestation(s) of this complication. Myxedema coma is a life- threatening complication that may occur with untreated hypothyroidism.
It is characterized by hyponatremia, hypotension, hypoglycemia, hypothermia, loss of consciousness, cardiovascular collapse, impaired cognition, and coma (LeMone et al. , 2011). These patients become hypersensitive to opioids and may die from normal doses (LeMone et al. , 2011). Myxedema coma may be brought on by trauma, infection, edications that depress the CNS, failure to take prescribed thyroid medications, and exposure to cold temperatures (LeMone et al. , 2011). The patient displays some symptoms of myxedema such as hypotension, hypothermia, feeling cold and increase memory loss.
Myexedema can also cause non-pitting edema, which is manifested in Mrs. Baksh as facial puffiness, a thick tongue, and periorbital edema. Bradycardia, hypotension and fluid accumulation in the pericardial sac may occur, as a deficit in thyroid hormone may cause a reduction in heart rate and stroke volume, resulting in decreased cardiac output. Coronary artery disease may also be present, further compromising cardiac function and increasing the patient’s risk for cardiovascular collapse (LeMone et al, 2011).
5. What’s the pathophysiological basis for Mrs. Baksh’s vital signs? Explain in detail. Low blood pressure and heart rate – Decreased renal blood flow and glomerular filtration rate reduces the kidney’s ability to excrete water (LeMone et al. , 2011). This occurs due to a deficit in the thyroid hormones. Decreased blood flow causes low glomerular hydrostatic pressure, decreasing filtrate rate (VanMeter & Hubert, 2014). As a result of decreased peripheral lood flow, the patient blood pressure becomes low. The decrease in water excretion causes the body to retain water causing the periorbital edema, which is also a participating factor in her generalized weakness.
A deficit in thyroid hormone causes a reduction in heart rate and stroke volume, resulting in decreased cardiac output, which accounts for the patient having bradycardia (LeMone et al. , 2011). Low temperature – Due to low thyroid hormone levels, it decreases the body metabolic rate and heat production (LeMone et al. , 2014). With a decrease in the metabolic process there is less consumption of energy. In ormal situations, T4 causes increase cellular metabolism throughout the body by stimulating heat production by chemical thermogenesis (Kozier et al. 2014). With low T4 levels, cellular metabolism is lost causing a loss in heat production. As a result of low thyroid hormone levels, the patient will manifest low body temperature. High respiratory rate – The patient’s oxygen saturation is normal. Dyspnea may be caused by decrease diaphragmatic function, which may affect the breathing pattern of the patient, explaining the tachypnea (Martinez et al. , 1989).
6. What is the significance of the abnormal laboratory and iagnostic results? Hypothyroidism caused by autoimmune diseases causes low serum TH (T3 and T4) levels as a result of decrease release from the thyroid, because as functional thyroid tissue is loss, it is replaced by nonfunctional fibrous tissue (LeMone et al. , 2011). Low serum TH may also be caused by insufficient iodine, as iodine is required for the biosynthesis of T4 and T3. Although the thyroid produces both T4 and T3, only T3 is the active thyroid hormone (T4 will eventually be converted into T3 within tissues), as it binds to thyroid hormone receptors (Adams et al. , 2010). Therefore in consequence, low T4 roduction will result in low T3.
With low TH levels, serum TSH level is elevated. Low TH stimulates the hypothalamus to secret thyroid releasing hormone (TRH). TRH stimulates the pituitary gland to secret thyroid stimulating hormone (TSH), which then stimulates the thyroid gland to release TH. Within a normal situation, rising levels of TH in the blood triggers a negative feedback response to shut off secretion of TRH and TSH. However, the negative hormonal feedback system may be loss due to decrease functional thyroid tissue, as a result of autoimmune disorder (LeMone et al. , 2011). Therefore TSH levels remain elevated.
The patient’s cholesterol levels are elevated due to a decrease in metabolic rate. Thyroid hormones are key metabolic hormones that play a critical role in controlling the rate of metabolic reactions in the body (Adams et al. , 2010). With low T3 and T4 levels, it causes a decrease in the metabolic rate, which causes a decrease in lipid metabolism in the body, leading to the accumulation of cholesterol.
According to Pucci et al. , TH stimulates increase mobilization of triglycerides to be stored in adipose tissue and stimulates the elimination of low-density lipoproteins (LDL) (Pucci et al. 000). Within a hypothyroid patient, low levels of TH causes triglycerides to accumulate in the blood and causes LDL to be absorbed by the liver, reducing its excretion, putting the patient at risk of developing hypercholesterolemia and hyperlipidemia (Pucci et al. , 2000). A high level of LDL and cholesterol predisposes the patient of health risks such as atherosclerosis, myocardial infarction and/or stroke. In addition, the patient has type 2 diabetes, which is associated with high blood lipids levels.
Based on the physical assessment done the patient had a firm enlarged thyroid gland, the ultrasounds is used to identify whether the thyroid gland is benign or cancerous. It is also used to determine the accurate size and to determine the vascular pattern of the thyroid gland. Ultrasound scanning is a noninvasive, widely available tool. It does not use any ionizing radiation and helps provide a visual guide of the gland (Chaudhary & Bano, 2013). An ECG was done for the patient because the patient is at risk of developing cardiomegaly (i. e. bradycardia, ventricular fibrillation) secondary to hypothyroidism (VanMeter et al. 014). The ECG detects the conductive and contractive activity of the heart, as well as the cardiac rhythm (LeMone et al. , 2011).
7. Explain the use of levothyroxine (Eltroxin) in the treatment and management of Mrs. Baksh’s hypothyroidism. What cardiac manifestation(s) needs to be monitored with the use of this medication and why? Levothyroxine is a synthetically prepared hormone used to treat hypothyroidism or prevent hypothyroidism in individuals lacking a thyroid gland, experiencing thyroid atrophy, undergoing radiation or taking antithyroid medications (Wilson et al. 016). Levothyroxine is chemically identical to the endogenous thyroid hormone thyroxine (T4) and therefore its function is also identical – the hormone gets converted into the hormone T3 within cells, where it binds receptors to regulate metabolic processes (Adams et al. , 2010). Therefore, the effects levothyroxine would have on the patient would be increase in body temperature, weight loss, decrease in swelling, and increase in activity tolerance due to increase energy production.
When the patient is under thyroid hormone replacement therapy, it is important to monitor the patient’s heart rate and blood pressure, especially with patients with undiagnosed heart disease, because cardiac collapse may occur (Adams et al. , 2010). The patient may experience cardiac manifestations such as tachycardia, arrhythmias, palpitations, angina and hypertension (Wilson et al. , 2016). These manifestations may occur due levothyroxine increasing basal metabolic rate, which causing increase in cardiac output, oxygen demand on the heart and myocardial contractility.
8. Mrs. Baksh reported weight gain of 6. 8kg (15lbs). What type of diet would be appropriate for this patient? Provide a rationale. Both weight gain and lack of an appetite are both a manifestation of hypothyroidism (LeMone et al. , 2011). She has a past history of type 2 diabetes, hypertension, and she is also constipated. A diabetic diet, as well as a low fat and cholesterol diet will be appropriate for this this patient because she has type 2 diabetes and high cholesterol levels, and therefore her sugar and fat/cholesterol intake needs to be monitored (Kozier et al. , 2014).
The patient should have three equal size meals with 4-5 hours apart, have small snacks in between and keep track of her calorie intake (LeMone et al. , 2011). Increasing water intake would benefit the patient’s constipation, blood volume and dry skin. In addition, a high fiber diet will help in preventing constipation. However, she needs to avoid excessive intake of high fiber foods because it is known to inhibit TH utilization. Along with this diet, she needs to include foods containing iodine (e. g. seafood, shellfish, eggs, etc. ) to improve thyroid function (Adams et al. , 2014).
