PATIENT PROFILE
A 29 year old female Caucasian who has a 7-month history of heavy irregular menses, a 5-pound weight gain, constipation and history of decreased energy
SUBJECTIVE
There is a family history of thyroid disease in the patient's mother (Nissenson, A. R., 2009). Moreover, from the physical examination, the patient is overweight with a body mass index of 26.09 kg/m/m. Computed Tomography also shows enlargement of the thyroid gland without the presence of any nodule.
OBJECTIVE
Thyroid function test which includes serum thyrotropin concentrations and ; thyroxine, resin triiodothyronine uptake; free thyroxine index (FTI), Thyroxine, Thyroid stimulating Hormone are all serum parameters that are measured. clinical signs like heart rate, blood pressure, and other clinical signs of hypo- and hyperthyroidism are all monitored.
TSH is the most reliable indicator for evaluating adequacy of thyroid replacement dosage (Sherwood, L., 2007). It may be elevated during the initial phase of treatment [first few months] of thyroid replacement despite patients being clinically euthyroid.
the TSH levels are monitored every 6-8 weeks until it normalizes; 8-12 weeks after dosage changes; every 6-12 months throughout therapy for thyroid hormone replacement.
Lab results
Preliminary wound culture positive for Gm + cocci.
CBC- Hct 33, Hgb 10.8, WBC 16.2, Bands 16.2, Neut 84, Lymphs 12. BUN 16, Creat 1.1, CPK 963, Pro 6.8, Alb 2.3, BS 92.
DX: Necrotizing Fasciitis
Large amount of murky dishwater like drainage noted. Wound copiously irrigated with saline. A wound VAC is placed into the 22 x 22 x 7 cm wound. He returns to surgery the following day for further debridement and dressing change and once more two days later for further debridement and dressing change (Kasper, G.L., 2005). Subsequent dressing change two days later reveals healthy viable granulating tissue with no further necrosis. Wound cultures are positive for Group A Streptococcus (GAS) only
When a patient presents with a rash, body itching or swelling, severe dizziness or when the patient has trouble breathing, these are indications that the medication should be switched to the second line agent (Kasper, G.L., 2005). Liothyronoine would be considered in patients in which there is need for rapid action of Thyroxine for instance in cases of severe hypothyroidism. Also, in cases when the conversion of Levothyroxinee to lithothyroine is impaired in the peripheral tissue. It is important to educate the patient to take the Levothyroxinee tablets on empty stomach because the presence of food in the intestines interferes with the absorption of Levothyroxinee in the intestines. The drug should be taken about two hours before food (Silverman, M.N. et al., 2005).
In addition, caffeine also inhibits the absorption of Levothyroxinee in the gastrointestinal tract. On discharge, the patient is counseled on all the medications she is taking, including the dosage and side effects and potential drug interactions. The patient is instructed to count her pulse at least twice in a week and report to the physician if the pulse rate goes above 100 beats per minute (Colombo, L; D. et al., 2006). The most sensitive tool for screening for primary hypothyroidism is the assay of Thyroid stimulating hormone. If the level of the thyroid stimulating hormone is above the normal reference range (4.5 - 10 mIU/L), an assay of the level of the free Thyroxine is done.
References
Colombo, L; D. et al (2006). "Aldosterone and the conquest of land.". Journal of
endocrinological investigation 29 (4): 373–9.
Kasper, G.L. (2005). Harrison's Principles of Internal Medicine. McGraw Hill.
Nissenson, A. R. (2009). Current diagnosis & treatment. New York: McGraw-Hill Medical.
Sherwood, L. (2007). Human Physiology: From Cells to Systems. Wadsworth Pub Co
Silverman, M.N. et al. (2005). "Immune Modulation of the Hypothalamic-Pituitary-Adrenal
(HPA) Axis during Viral Infection" Viral Immunology 18 (1): 41–78.
