Select a client from clinical experience with an acute health problem or complaint requiring at least two visits. Submit a complete H & P from the initial visit with this client and a focused SOAP note for the follow-up visit. Based on this clients condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer reviewed articles must address the standardized procedure or guidelines for this diagnosis. Incorporate the research findings into the decision-making for this clients treatment. In the paper, compare and contrast or address how treatment or the plan may have been different based on the research findings. The discussion on relating research to practice should be 3-4 pages and the total paper should be no longer than 10 pages including references. The research articles must be an original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Cover the criteria listed below. The paper should be APA formatted and no longer than 10 pages. Reviews topic and explains rationale for its selection in the context of client care. (2 pts)Evaluates key concepts related to the topic. 2 pts)Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines. (2 pts)Assesses the merit of evidence found on this topic i.e. soundness of research (5pts)Evaluates current EBM guidelines, if available. Or, recommends what these guidelines should be based on available research. Discuss the Standardized Procedure for this diagnosis. (5 pts)Discusses how the evidence did impact/would impact practice. What should be done differently based on the knowledge gained? (3 pts)Consider cultural, spiritual, and socioeconomic issues as applicable. (2pts).Utilizes APA guidelines, cite references (2 pts)Writing style at the graduate level (2pts)
Hyperthyroid EBP
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Hyperthyroid EBP
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SUBJECTIVE DATA
ID: TS is 29-year-old Caucasian female DOB 2/1994, presents to the clinic with complaints of
palpitation. She came to the clinic alone, and she is a dependable historian.
CC: “I have been having palpitation for 3-4 weeks now.”
HPI: TS is a 29-year-old Caucasian female who presents with several weeks of palpitations with
associated dyspnea. The episode comes on suddenly and lasts for about four to five minutes. She
also notes a ten-pound unintentional weight loss, nervousness, increased sweating, and having lost
bowel movement. She denies chest pain or pressure dizziness associated with palpitation. She is a
smoker for the past 5 years. She denies recreational drugs and occasionally drinks alcohol. She
works as a secretary in a very busy business administration office. She reports being stressed at
the job. She is able to enjoy her time off with her husband and children. In addition, she reports
being stressed at home due to her parents being infected with Covid-19. She also reports she does
not have any friends to talk to or relieve her stress. Have been feeling anxious and restless. She
drinks 2 cups of coffee daily and denies drinking energy drinks. She denies using the recreational
drug and admits to using a small amount of alcohol. She denies taking over-the-counter medication
or prescribed medication.
PMH
Allergies: No known allergies to food, drug, environmental
Medications: none
Hyperthyroid EBP
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Surgeries: No surgical history
Hospitalizations: Denies
Immunization: All immunization up to date, including influenza and Covid-19
Past Medical History: none
Family Medical History: Mother: 64 years old Hypertension; Father: 65 years old, Diabetes
mellitus type 2; Brother 24 years old healthy; Sister 26 years old healthy; Daughter 7 years old
healthy; Son 5 years old healthy
Social History:
History of smoking during high school for 4 years and quit. Denies recreation drugs. Admits to
using a small amount of alcohol Exercise: 3-4 times a day. Diet: Eats healthy, including portions,
and includes fruit, vegetable, dairy, meat, grains in her diet. Drinks 2 cups of coffee a day. Denies
drinking energy drinks or caffeinated products. Economic/living situation: lives with husband and
children. she has a reliable source of income. Safety: Practice safe driving by not texting while
driving and using a seat belt. Feels safe at home. Denies having guns at home. Religion: She is
Christian and denies religion playing a role in healthcare decisions. She goes to church every
Sunday with her family.
ROS
Constitutional: Denies fever, chills, or fatigue. Reports losing 10 pounds within the last few
weeks.
Hyperthyroid EBP
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HEENT: Ear: Denies earache, ear ringing Eyes: Denies blurry vision. Nose: denies runny nose.
Denies sore throat or lesion, or abscess in the mouth. Denies pain in the sinuses or lymph nodes.
Cardiovascular: denies chest pain or irregular heart rate. Reports palpitations with shortness of
breath
Pulmonary: Denies difficulty breathing or cough. But reports shortness of breath after
palpitations.
Gastrointestinal: Denies abdomen pain or loss of appetite. Reports increase in bowel movement.
Denies blood in the stool or urine.
Integumentary & breast: Denies nipple discharge, skin bleeding, delayed healing, eczema, skin
lesions, and pigmentation.
Neurological: Reports nervousness and feeling shaky when she is having palpitations. Reports
having tremors and restlessness.
Psychiatric: reports being stressed at home and work, feeling anxious and restless.
Endocrine: Reports increase sweating, racing heart rate, and weight loss.
Hematologic/Lymphatic: Denies easy bruising or bleeding. Denies tender lymph nodes.
Allergic/Immunologic: Denies allergies to an environmental factor.
OBJECTIVE DATA
Vital Signs: HR: 96 BP: 117/71
air Pain: 0/10 Height: 66″
Temp: 97.8 F
RR: 17 bpm SpO2: 99% on room
Weight: 125lbs (12 pounds less a year ago)
BMI: 20.2
Hyperthyroid EBP
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Physical Exam:
General survey: She is awake, alert, and of appropriate age. She is fidgety and anxious. Mood
and affect are stable. She has a good thought process and can make decisions. But seems concerned
with palpitation and dyspnea.
HEENT: She has bulging eyes, and lid lag is present. The thyroid is enlarged bilaterally and
symmetrically. No tenderness to palpation of the thyroid gland. No palpable nodules were noted.
Tympanic membrane pearly grey and cone of light is present. The nose is symmetrical without
discharge. Mucosa and Turbinates’ are pink and moist. The pink and moist mucous membrane, no
lesion in the mouth noted. The buccal mucosa is pink and moist. No erythema was noted on the
pharynx. Tongue and uvula are midline.
Cardiovascular: No rashes, lifts, or heaves noted. The chest is even and symmetrical. No murmur
was noted. S1 and S2 and regular hearth beat. +2 pulses in all extremities. S3 and S4 are absent.
Pulmonary: lungs clear to auscultation in all fields, no wheezing, crackles, or rales.
GI: abdomen is even and symmetrical, no rash or scars noted. Hyperactive bowel sound. Abdomen
soft and non-tender, no guarding. No HSM, no CVA tenderness.
Integumentary: fine hair, brittle hair and warm skin. No lesions or rash.
Hematology/Lymphatic: enlarged thyroid, and no tenderness. No bruising or bleeding noted.
Neuro: fine tremors noted with hyper-reflexes. Clear speech with a clear tone. Upright posture.
Normal gait.
Hyperthyroid EBP
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Psych: anxious with non-pressured speech. She is alert, oriented, and maintains eye contact.
ASSESSMENT
A. Differential diagnoses
i.
Hyperthyroidism (Graves’ Disease) (E05.90) Hyperthyroidism is the most likely
diagnosis as evidenced by palpitation with shortness of breath, restlessness, tremors,
exophthalmos, increase in BM, weight loss, and enlarged thyroid. The signs and symptoms
of overt hyperthyroidism are frequently quite severe (Ross, 2020). According to Ross
(2020), among the many hyperthyroid symptoms that might manifest are heat sensitivity,
nervousness, palpitations and anxiety, weight loss despite normal or increased appetite,
increased bowel frequency, and shortness of breath.
ii.
Anemia (64.9) This is less likely the diagnosis as evidenced by palpitation with shortness
of breath, restlessness, tremors, exophthalmos, increase in BM, weight loss, and
hyperreflexia. A report from the Mayo Clinic (2021) states that the symptoms of anemia
include excessive weariness and weakness, chest discomfort and palpitations; chilly hands
and feet; and a poor appetite. Iron deficiency anemia is a serious condition that affects
women, children, and vegetarians (Mayo Clinic, 2021).
B. Panic disorder (F41.0) Panic disorder is a potential diagnosis due to symptoms such as
palpitations, sweating, trembling or shaking, shortness of breath, a feeling of choking, chest
pain, nausea, dizziness, chills or heat sensations, paresthesia, derealization or
depersonalization, fear of losing control or going insane, and fear of dying. Leibold &
Schruers (2018) point out that panic disorder manifests itself in the form of sudden panic
attacks that occur regularly. The individual is continuously afraid of having another panic
Hyperthyroid EBP
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attack. According to Memon (2018), it is possible to have a panic attack without any
indication of what caused it, or it is possible to have a panic attack when you least anticipate
it, for example, in reaction to a feared item or scenario.
Final Diagnosis: Hyperthyroidism-This is the primary and final diagnosis for this patient due
to hallmark signs and symptoms that characterize the disease. They include palpitation,
shortness of breath, nervousness, increased bowel movements, weight loss, restlessness,
anxiety, and increased sweating.
PLANNING
Diagnostics
EKG to rule out cardiac causes
Labs Thyroid essay with T3, T4, CBC, C-reactive protein, ESR. According to Ross (2020),
to rule out hyperthyroidism, and autonomously functioning thyroid adenoma, TSH, serumfree T4, and T3 must be measured. According to Dunphy et al. (2019), The serum-sensitive
TSH test identifies suppressed levels in the presence of higher thyroid hormones, T4 and
T3, when the thyroid hormones are elevated. If the thyroid-stimulating hormone (TSH) is
low, adding free thyroxine immunoassay (FT4) and thyroid hormone (T3) may save time
and money (Dunphy et al., 2019).
CBC. According to Cash and Glass (2018), a complete blood count (CBC) is required to
rule out anemia.
Radioiodine uptake -Determine if the patient has iodine-induced thyroiditis, Graves’
disease, toxic multinodular goiter, or a toxic adenoma before proceeding (Ross, 2020)
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Plan: follow up appoint after all the results are back within the a week
Subjective Data
HPI: TS is a 29-year-old Caucasian female who presents with continue palpitations with dyspnea,
nervousness, increased sweating, feeling anxious and restless, increased bowel movement and
change in menstrual cycle. No relief in her symptoms following up on her labs and diagnostic
results.
Constitutional: Denies fever, chills, or fatigue. Reports losing 10 pounds within the last few
weeks.
Eyes: Denies blurry vision. Changes in vision
Neck: Denies tender or swollen lymph nodes.
Cardiovascular: denies chest pain or irregular heart rate. Reports palpitations with shortness of
breath
Pulmonary: Denies difficulty breathing or cough.
Gastrointestinal: Reports increase in bowel movement. Denies blood in the stool or urine.
Integumentary & breast: Denies skin lesions or rash. Reports moist skin
Neurological: Reports nervousness and feeling shaky when she is having palpitations. Reports
having tremors and restlessness.
Psychiatric: reports being stressed at home and work, feeling anxious and restless.
Hyperthyroid EBP
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Endocrine: Reports increase sweating, racing heart rate, and weight loss.
Objective Data
Vital Signs: HR: 110 BP: 115/71
0/10
Height: 66″
Temp: 97.6 F RR: 17 bpm SpO2: 99% on room air Pain:
Weight: 124lbs (13 pounds less a year ago)
BMI: 20.1
Physical Exam
General survey: She is awake, and alert, and with appropriate age. She is fidgety and anxious.
Mood and affect is stable. She has good thought process and able to make decisions.
Eyes: she is noted to have bulging eyes, and lid lag is present. Thyroid is enlarged bilaterally and
symmetrically. No tenderness to palpation of thyroid gland. No palpable nodules noted.
Cardiovascular: No lifts, or heaves. The chest is even and symmetrical. No murmur noted.
S1S2 and regular hearth beat. +2 pulses in all extremities. No edema. Carotid no bruit noted.
Pulmonary: lungs clear to auscultation, no wheezing, crackles, or rales. Dyspnea noted
GI/GU: abdomen is even and symmetrical, no rash or scars noted. Hyperactive bowel sound.
Abdomen soft and non-tender to palpation, no guarding. No HSM, no CVA tenderness.
Integumentary: fine hair, brittle hair and warm skin. No lesions or rash.
Hyperthyroid EBP
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Neuro: fine tremors noted with hyperreflexia. Alert and oriented x 3.
Psych: anxious with non-pressured speech. Thoughts are congruent and intact.
Assessment
Final diagnosis: Hyperthyroid (Graves Disease) as evidenced by Lab results, diagnostics and
sign and symptoms.
Plan
Labs are back the next day and show hyperthyroid with TSH decreased, and serum-free T4
increased. Hemoglobin and hematocrit within the expected range. EKG Sinus rhythm. Radiodine
scan confirms hyperthyroid.
a. Treatment: Start patient on Methimazole 5 mg by mouth daily
b. Follow-up Follow up in 4 weeks to re-evaluate
Literature Search
Hyperthyroidism review and rationale for its selection in the content of client care.
Based on the clients’ condition, this paper will solicit information mainly on these peerreviewed articles; Hyperthyroidism. Gland Surgery, 9(1), 124135 by Doubleday & Sippel, (2020)
and hyperthyroidism (overactive thyroid) (Beyond the Basics) by Ross, (2021). However, it will
still incorporate literature from other peer-reviewed sources.
Hyperthyroid EBP
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Hyperthyroidism, also known as overactive thyroid, is excessive concertation or thyroid
hormone in the tissues due to excessive secretion of preformed thyroid hormones, increased
synthesis of thyroid hormones, or exogenous endogenous extrathyroidal source (Mathew, Rawla
& Fortes, 2021). In the USA, Graves’ Disease is the leading cause of hyperthyroidism among the
young population, while in the aged population, toxic multinodular goiter is the most common
cause (Doubleday & Sippel, 2020; Ross, 2021). Other causes of hyperthyroidism include thyroid
adenomas, iodine-induced hyperthyroidism, factitious thyroiditis, postpartum thyroiditis, and
subacute thyroiditis (Doubleday & Sippel, 2020; Ross, 2021).
In the context of client care, hyperthyroidism has a clinical significance as it occurs in 1.3%
of the population but increase to 4-5% in older women; it is more predominant in the female
population than in males and more common in smokers (Domino, 2020; Ross, 2021). When left
untreated, hyperthyroidism can cause health complications like thinning bones, heart failure,
stroke, blood clots, irregular heart, Graves’ ophthalmopathy, muscle problems, osteoporosis,
fertility, and menstrual cycle issues (NIDDK, 2021). Hyperthyroidism occurred to TS due to risk
of the female gender, smoking, and family history of autoimmune diseases. According to Domino
(2020); NIDDK (2021), the predisposing factors include; female gender, positive family history
of thyroid disease, pernicious anemia, diabetes, use of nicotine products, pregnancy (over 6
months), use of medications and foods that contain iodine, other autoimmune disorders iodide
repletion after iodide deprivation.
Hyperthyroidism key concepts.
Hyperthyroidism is a condition that is marked by too much secretion of thyroid hormones
by the thyroid gland. In the USA, the prevalence is 1.3% (Ross, 2021). Hyperthyroidism clinical
Hyperthyroid EBP
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manifestation can differ from patient to patient since the thyroid hormone can impact various
systemic symptoms. The cellular effects of Triiodothyronine (T3) binding to alpha and beta
receptors increase basal and thermogenesis metabolic rates. In turn, this causes constitutional
symptoms like fatigue, weight loss, dysphagia, thinning hair, heat intolerance, weakness,
osteoporosis, increased bone resorption, lymphadenopathy, increased hunger, increased stool
frequency (over three times daily), anxiety, irritability, frequent bowel movement, tremors
cardiovascular events (Doubleday & Sippel, 2020; Ross, 2021). Several studies that focus on
preventing hyperthyroidism point out that the condition requires interprofessional care approach
and regular monitoring.
Controversies in diagnosis and treatment and merit of evidence found on this topic
The selected articles present clear guidelines for the diagnosis and treatment of
hyperthyroidism. The diagnosis can be ordered through thyroid blood tests to measure the amount
of thyroid hormone and thyroid-stimulating hormone (TSH) (Ross, 2021). According to
Doubleday & Sippel (2020), the thyroid-stimulating hormone test is the most sensitive test to
examine thyroid function, while T4 and total serum T3 can be ordered as confirmatory tests when
the thyrotoxicosis is highly suspected or to further assess abnormal TSH levels (Doubleday &
Sippel, 2020). Overt hyperthyroidism will manifest high T3/T4 and low TSH levels (Doubleday
& Sippel, 2020). Subclinical hyperthyroidism will present normal T3 and T4 and low TSH levels
(Doubleday & Sippel, 2020). Similarly, Ross (2021) argues that hyperthyroidism is characterized
by low TSH levels and high thyroid hormone levels.
In addition to blood work, imaging tests can confirm the diagnosis and rule out other
diseases. For instance, a thyroid scan can help determine hyperthyroidism etiology, whether
Hyperthyroid EBP
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thyroiditis, toxic nodular goiter, or Graves’ disease (Ross, 2021). Thyroiditis will show higher T4
and low T3 levels, while Graves’ diseases will have positive thyrotropin receptor antibodies
(Doubleday & Sippel, 2020). EKG to rule out cardiac diseases. A radioactive iodine uptake
(RAIU) test is crucial for diagnosis and treatment plan since it can help differentiate between
Graves’ diseases (GD), toxic adenomas (TA), and toxic multinodular goiters (TMNGs). In GD, the
test will show diffuse radioactive iodine uptake in the thyroid gland. TA will show a localized area
of uptake without uptake in the remaining gland, and TMNG will show irregular uptake patterns
(Doubleday & Sippel, 2020). The treatment options for hyperthyroidism are dependent on the
etiology severity of the symptoms to normalize the thyroid hormone levels. They include
Antithyroid medication (Methimazole), surgery, and radioiodine-RAIT. The available research
offers reliable and abundant evidence for accurate diagnosis, which prompts appropriate treatment.
Current EBM guidelines and Standardized Procedure for diagnosis.
The American Thyroid Association provides guidelines and standardized procedures for
diagnosing and managing hyperthyroidism. The ATA guidelines recommend that for the diagnosis
of hyperthyroidism, the diagnostic workup entails measuring thyroid-stimulating hormone (TSH),
free thyroxine (T4), and total triiodothyronine (T3) levels to assess the presence and severity of
the disease. Also, the guidelines assert that radioactive iodine uptake and thyroid gland can be
performed to evaluate or determine the etiology (Ross et al., 2016). Accordingly, the American
Society for Clinical Pathology discourages ordering multiple tests during the initial tests in patients
suspected of thyroid complications. Instead, it recommends a TSH test and if results are abnormal,
proceed with additional tests and treatment based on the results. Also, the American Association
Hyperthyroid EBP
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of Clinical Endocrinologists discourages ordering thyroid ultrasound in persons with abnormal
thyroid function tests if there is no palpable thyroid gland abnormality.
According to the ATA guidelines, Methimazole is the first-line and preferred antithyroid
medication to treat hyperthyroidism except in patients allergic to the medication or women in the
first trimester of pregnancy (Ross et al., 2016). These guidelines and procedures for diagnosing
and managing hyperthyroidism are backed with grade B and C evidence implying that the
healthcare provider should order the service to the eligible.
Impact on practice and what should be done differently based on the knowledge gained
Following the ATA guidelines, the treatment for patient TS will be positively impacted.
The guidelines will help the clinician appropriately diagnose and treat hyperthyroidism without
contraindication. The treatment for TS will include administering Methimazole because the
research reveals that antithyroid medications inhibit thyroid peroxidase, blocking T3 and T4
synthesis. As a result, this helps normalize thyroid function, prevent hyperthyroidism exacerbation,
and avoid surgical risks due to untreated hyperthyroidism. The research proves that the patient can
benefit from the therapy. Based on the evidence, TS requires collaborative and interprofessional
care approach and follow-up appointments. Lastly, patient education is key to the management
and treatment of any diseases; thus, the patient should be educated about medication compliance.
In addition, the patient should be educated to avoid caffeine, smoking cessation, stress
management therapy, avoid foods/substances rich in iodine.
Planning for patient care with hyperthyroidism should consider cultural, spiritual, and
socioeconomic factors. This was not pertinent for TS. However, patient education concerns could
impact the care. TS admits she is a smoker; she should be educated to cease smoking. Secondly,
Hyperthyroid EBP
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she verbalizes stress hence the need for stress management. These factors could have increased the
patient’s risk for the condition hence need to be addressed. Lastly, the physician must understand
that the patient may have financial constraints or reliable transport (does not have a vehicle), which
are essential for increased visitation compliance; thus, accommodation should be made or
suggested. TS is of Caucasian dialect and Christin but admits religion does not play a role in
healthcare decisions.
Conclusion
Hyperthyroidism is a medical term used to describe the thyroid gland’s inappropriate high
production of thyroid hormones (Mathew, Rawla & Fortes, 2021; Ross, 2021). When this occurs,
it results in thyrotoxicosis (a condition where there is excess thyroid hormone on the tissues
causing systemic clinical manifestations) and increases the body’s metabolism. Based on the
information coved above, hyperthyroidism is life-threatening and can pose a significant burden to
one’s daily routine. The condition can present with an array of symptoms, and if not properly
managed, it can result in poor quality of life. Since there exist various causes of hyperthyroidism,
it can best be managed through a collaborative approach by an interprofessional team along with
the prescription of medication. The team must use current evidence clinical practice guidelines to
ensure the patient gets the appropriate standard of care.
Hyperthyroid EBP
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References
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Domino, F. J., Barry, K., Baldor, R. A., & Golding, J. (2020). 5-minute clinical consult 2021 (the
5-minute consult series) (29th ed.). Wolters Kluwer Health.
Doubleday, A. R., & Sippel, R. S. (2020). Hyperthyroidism. Gland Surgery, 9(1), 124135.
https://doi.org/10.21037/gs.2019.11.01
Dunphy, M., Winland-Brown, E., Porter, O., & Thomas, J. (2019). Primary care: Art and science
of advanced practice nursing – an interprofessional approach (5th ed.). F.A. Davis
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