KC Module 4

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KC Module 4 QUESTION 1 1. A 67-year-old Caucasian woman was brought to the clinic by her son who stated that his mother had become slightly confused over the past several days. She had been stumblin ... g at home and had fallen once but was able to ambulate with some difficulty. She had no other obvious problems and had been eating and drinking. The son became concerned when she forgot her son’s name, so he thought he better bring her to the clinic. PMH-Type II diabetes mellitus (DM) with peripheral neuropathy x 20 years. COPD. Depression after death of spouse several months ago Social/family hx - non contributary except for 30 pack/year history tobacco use. Meds: Metformin 500 mg po BID, ASA 81 mg po q am, escitalopram (Lexapro) 5 mg po q am started 2 months ago Labs-CBC WNL; Chem 7- Glucose-92 mg/dl, BUN 18 mg/dl, Creatinine 1.1 mg/dl, Na+120 mmol/L, K+4.2 mmol/L, CO237 m mol/L, Cl-97 mmol/L. The APRN refers the patient to the ED and called endocrinology for a consult for diagnosis and management of syndrome of inappropriate antidiuretic hormone (SIADH). Question: Define SIADH and identify any patient characteristics that may have contributed to the development of SIADH. SIADH is a condition in which high levels of a ADH cause the body to retain water. The body retains water instead of excreting it normally in urine. This process upsets the body's balance of electrolytes, especially sodium. One characteristic that may have contributed to the development of SIADH in this patient is the use of metformin, which is a hypoglycemic drug used to treat type II diabetes. Antidepressants such as escitalopram can contribute to the development of SIADH as well. The trauma of the fall could have also contributed to the development of SIADH. 2) A 43-year-old female presents to the clinic with a chief complaint of fever, chills, nausea and vomiting and weakness. She has been unable to keep any food, liquids or medications down. The symptoms began 3 days ago and have not responded to ibuprofen, acetaminophen, or Nyquil when she tried to take them. The temperature has reached as high as 102˚F. Allergies: none known to drugs or food or environmental Medications-20 mg prednisone po qd, omeprazole 10 po qam PMH-significant for 20-year history of steroid dependent rheumatoid arthritis (RA). GERD. No other significant illnesses or surgeries. Social-denies alcohol, illicit drugs, vaping, tobacco use Physical exam Thin, ill appearing woman who is sitting in exam room chair as she said she was too weak to climb on the exam table. VS Temp 101.2˚F, BP 98/64, pulse 110, Resp 16, PaO2 96% on room air. ROS negative other than GI symptoms. Based on the patient’s clinical presentation, the APRN diagnoses the patient as having secondary hypocortisolism due to the lack of prednisone the patient was taking for her RA secondary to vomiting. 2) Question: Explain why the patient exhibited these symptoms? The patient was experiencing hypocortisolism due to the lack of the prednisone to stimulate the ACTH to produce cortisol. ACTH, secreted by the anterior pituitary gland, stimulates synthesis of cortisol and androgens in the adrenal cortex with long term use of glucocorticoids the adrenal glands atrophy and do not produce efficiently. Due to the vomiting the patient has not absorbed the glucocorticoids and has had a drop in the levels. QUESTION 3 A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had about of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 7 which revealed a serum Ca++ of 13.1 mg/dl. The APN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. 3) Question: What is the role of parathyroid hormone in the development of primary hyperparathyroidism? In many cases of primary hyperparathyroidism the parathyroid is not functioning properly and secreting excess thyroid hormone from one or both of the parathyroid glands. QUESTION 4 1. A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. 4)Question 1 of 2: Explain the processes involved in the formation of renal stones in patients with hyperparathyroidism Renal stones develop due to the excess secretion of calcium from the bones and the GI tract. The calcium level in the blood increases because of increased bone resorption and gastrointestinal absorption of calcium but fails to inhibit PTH secretion at normal levels of calcium because the feedback threshold for calcium is set at a higher level in the abnormal parathyroid tissue. This increase in circulating calcium. The Calcium phosphate salts precipitate in alkaline urine, renal pelvis, and collecting duct which causes the formation of calcium oxalate stones. QUESTION 5 1. A 64-year-old Caucasian female presents to the clinic with vague symptoms of non- specific abdominal pain, myalgias, constipation, polyuria, and says she feels “fuzzy headed” much of the time. She had a fracture of her right metatarsal without trauma and currently is wearing a walking boot. She also had a bout of kidney stones a few weeks ago and she fortunately was able to pass the small stones without requiring lithotripsy or other interventions. She was told by the urologist to follow up with her primary care provider after the kidney stones has resolved. The APRN examining the patient orders a Chem 12 which revealed a serum Ca++ of 13.1 mg/dl. The APRN believes the patient has primary hyperparathyroidism and refers the patient to an endocrinologist who does a complete work up and concurs with the APRN’s diagnosis. 5)Question 2 of 2: Explain how a patient with hyperparathyroidism is at risk for bone fractures. A patient with hyperparathyroidism is at risk for bone fractures because the parathyroid hormone stimulated bone resorption which causes a weakness in the bones making the patient more susceptible to fractures. ......continued [Show More]

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