Download ACNP Problems II Case Studies I and II

Running head: langenhop_CASE STUDIES I AND II
ACNP Problems Case Studies I and II
Laura Langenhop
Wright State University
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langenhop_CASE STUDIES I AND II
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ACNP Problems II Case Studies I and II
1. What are the potential etiologies of this patient’s symptoms? (That is, what are the
differential diagnoses?) Provide rationale for your answer. Use a variety of references.
Prioritize your list from most likely diagnosis to least likely diagnosis.
Differential diagnoses for this patient include meningitis, pheochromocytoma, migraine,
subarachnoid hemorrhage, and thyroid storm. The most common cause of hyperthyroidism and
thyroid storm is Grave’s disease (Tintinalli et al., 2011). The patient in this case was diagnosed
with Grave’s disease one month prior to hospital admittance. Patients who are at risk for thyroid
storm are those who have received radioactive iodine, who have had surgery, those who have
given birth, those with severe illnesses such as diabetes mellitus, and those with an infection
(Lee & Masharani, 2012). Thyroid storm occurs most frequently in younger women (Tintinalli
et al., 2011). This patient is at risk for thyroid storm because of her young age and also because
the patient received radioactive iodine treatment several days prior to hospital admittance
(Hampton, 2013).
Thyroid storm is an exacerbation of thyrotoxicosis, or the overabundance of thyroid
hormone (Hampton, 2013). The thyroid hormones play a major part in thermogenic and
metabolic homeostasis (Hamptom, 2013). The lack of regulation of the thyroid hormones causes
the metabolic and thermoregulatory responses to be altered. Symptoms of thyroid storm include
a fever ranging from 38 degrees Celsius to 41 degrees Celsius, sweating, photophobia,
tachycardia, delirium, agitation, restlessness, nausea, vomiting, diarrhea, oligomenorrhea,
abdominal pain, and sometimes coma (Lee & Masharani, 2012). In this case, the patient’s
symptoms that align with the signs and symptoms of thyroid storm include a fever of 38.1
degrees Celsius, tachycardia, fatigue, weight loss, photophobia, oligomenorrhea, headache, and
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an enlarged thyroid with a prominent bruit. With the addition of the thyroid function tests, the
diagnosis of thyroid storm can be suspected in this patient (Hamptom, 2013).
Thyroid storm occurs when the thyrotropin receptor antibodies stimulate large amounts
of uncontrolled thyroidal synthesis and increase the secretion of thyroid hormones (Tintinalli et
al., 2011). Normal thyroid function tests include a thyroid stimulating hormone (TSH) level
between 0.5-5.0 mIU/mL, a triodothyronine (T3) level between 70-195 ng/dL, a free thyroxine
index (FTI) level 0.9-2.4 ng/dL, and a serum thyroxine (T4) level between 5-12 mcg/dL
(Hampton, 2013). The patient’s previous outpatient thyroid function tests showed a low level of
TSH and an elevated T4, FTI, T3, and the four-hour uptake was 58.8 %. In the emergency room,
the TSH was within normal limits at 0.92 mIU/mL, while the T3 and T4 were still elevated with
an incalculable FTI. The laboratory work received in the emergency room is consistent with
thyroid storm with the main findings being an elevated T3, T4, and FTI (Weiss & Refetoff,
2005).
The patient was previously diagnosed with Grave’s disease. The patient was treated with
radioactive iodine, which is typically given for a “hot thyroid nodule”, a portion of the thyroid
consuming a large amount of iodine (Flechas, 2012). When the thyroid consumes large amounts
of iodine, the body does not realize it and believes there is not enough iodine in the system and
therefore large amounts of T4 are secreted in order to compensate for it (Flechas, 2012).
Radioactive iodine is given in order to counteract the consumption of iodine from the thyroid and
reduce T4 levels. However, use of radioactive iodine without proper anti-thyroid regimen results
in a rare complication, thyroid storm, as seen by the patient is this case study (Flechas, 2012).
The patient presented to the emergency room with a headache and pain radiating to her
neck and a fever. The headaches and neck pain may signal meningitis. Meningitis can be either
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bacterial or viral in nature (Putz, Hayani, & Zar, 2013). Meningitis is defined as inflamed
meninges with an increased number of white blood cells in the cerebral spinal fluid (Putz,
Hayani, & Zar, 2013). Patients with meningitis have symptoms of headache, fever, nuchal
rigidity, photophobia, extremity weakness, and possible lymphadenopathy. Nuchal rigidity is a
highly sensitive test. With the absence of nuchal rigidity, a normal white blood cell count and
altered mental status make the diagnosis of meningitis unlikely (Putz, Hayani, & Zar, 2013).
Pheochromocytoma is another differential diagnosis. A pheochromocytoma is a well
vasculcularized tumor originating from the adrenal medulla or the carotid body (Neumann,
2012). Pheochromocytoma produces catecholamine’s causing palpitation, diaphoresis, and
headaches. Patients with pheochromocytoma also have hypertension and tachycardia.
Catecholamine crises from a pheochromocytoma can cause pulmonary edema, arrhythmias, and
intracranial hemorrhage (Neumann, 2012). These attacks typically occur in less than an hour and
may be precipitated by surgery, positional changes, exercise, pregnancy, urination, and various
medications such as tricyclic antidepressants (Neumann, 2012).
The patient in this scenario has a headache, fever, tachycardia, and hypertension. Urine
catecholamines would be ordered to diagnose a pheochromocytoma (Neumann, 2012). Plasma
metanephrines may also be ordered. A computerized-tomography scan of the adrenal glands also
would be ordered to view the tumor (Nuemann, 2012). The patient in this scenario has a mild
tachycardia, mild hypertension, and is without palpitations and diaphoresis. Pheochromocytoma
is a possible differential diagnosis, but due to the patient’s thyroid function studies and recent
iodine radiation treatment, the likely diagnosis is thyroid storm (Nuemann, 2012).
Subarachnoid hemorrhage should be considered in a patient with a severe headache. A
subarachnoid hemorrhage causes blood to compress against brain tissue leading to neurologic
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deficits (Greenberg, Aminoff, & Simon, 2012). Another issue that may arise from a
subarachnoid hemorrhage is vasospasms leading to re-injury and ischemia (Greenberg, Aminoff,
& Simon, 2012). Typically, patients with severe headaches admit to the emergency room
without signs and symptoms of neurologic problem. In this case, the patient presented with a
severe headache with a history of migraines. The patient has photophobia that has occurred over
the last month that has recently worsened. Through physical examination and thyroid function
testing, subarachnoid hemorrhage is a possible diagnosis but the cause of the patient’s headache
is most likely related to a different etiology (Greenberg, Aminoff, & Simon, 2012).
Since the patient has a history of migraines that are difficult to control, a migraine
headache is also a differential diagnosis for this case presentation. Migraine headaches present
with photophobia, phonophobia, nausea, vomiting, and are typically unilateral in nature (Stern,
Cifu, & Altkorn, 2010). The patient also has photophobia that has occurred over the last month
compounded with nausea and vomiting. The patient was without an aura or phonophobia. The
differences in this case are the patient’s other signs and symptoms. The patient has a fever,
abnormal thyroid function tests, thyroid bruit, right upper abdominal pain, tachycardia, and high
blood pressure. Though the patient’s headache could be a migraine, the actual etiology of the
patient’s problems is most likely from thyroid storm (Stern, Cifu, & Altkorn, 2010).
2. Which of the following is not considered a diagnostic criterion for thyroid storm? Bold
the correct answer. Provide rationale for your answer and why you eliminated the others.
A. Nausea and vomiting
B. Tachycardia
C. Tremor
D. Fever
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E. Pulmonary Edema
The diagnosis of thyroid storm can be difficult to make. Burch and Wartofsky developed
a point system in order to distinguish between thyrotoxicosis and thyroid storm (Tintinalli et al.,
2011). The point system includes seven categories. These seven categories are congestive heart
failure, atrial fibrillation, heart rate, fever, gastrointestinal-hepatic dysfunction, precipitating
events, and central nervous system effects (Paulson & Hollenberg, 2012). A total score >45 is
suggestive of a patient having thyroid storm (Tintinalli et al., 2011). The patient’s score in this
case is 55, based on clinical signs and symptoms.
Of the categories listed, nausea and vomiting, tachycardia, fever, and pulmonary edema
are all considered to be a part of the diagnostic criteria for the diagnosis of thyroid storm
(Paulson & Hollenberg, 2012). Metabolic and thermoregulatory dysfunction can cause the
patient to present with abdominal issues, fever, and tachycardia with the absence of tremor. A
patient may present with a tremor along with other symptoms, but it is not considered a
diagnostic criterion (Paulson & Hollenberg, 2012; Tintinalli et al., 2011). In the “central nervous
system effects” category, the only diagnostic criteria for thyroid storm are agitation, delirium,
psychosis, lethargy, seizure, and coma (Paulson & Hollenberg, 2012). Tremor is not considered
a diagnostic criterion for the diagnosis of thyroid storm (Paulson & Hollenberg, 2012).
3. Based on this patient’s symptoms and diagnostic studies, which of the following
management strategies is not appropriate? Provide rationale for your answer and why you
eliminated the others.
A. Ablation 1311 (RAI)
B. Thyroidectomy
C. B-Blocker and thionamide (popylthiouracil or methimazole)
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D. Lugol Solution
E. Corticosteroids
The management strategy that is inappropriate for the patient is the iodine ablation (RAI).
Following thyroid storm, patients need to wait until they are in a euthyroid state before they can
consider receiving RAI (Tintanalli et al., 2012). Typically, patients receive a RAI ablation after
a thyroidectomy in order to eliminate thyroid remnants and neoplasms, and to search for
persistent carcinomas (Schlumberger et al., 2012). An ablation following a thyroid storm is
contraindicated because the iodine administered into the thyroid gland can have an adverse effect
and worsen the thyroid function. By deteriorating the thyroid function, the thyroid storm could
become detrimental, placing the patient at risk for worsening symptoms and medical instability
(Tintinalli et al., 2012; Schlumberger et al., 2012).
Beta-blockers are used in patients with thyroid storm to control the excessive adrenergic
response (Lee & Masharani, 2012). Medications, such as Propanolol or Atenolol, are used to
help prevent the conversion of T4 to T3 (Lee & Marsharani, 2012). Beta-blockers conversely
help to treat tachycardia as well as high blood pressure in patients. Beta-blockers are used until
Free T4 and T3 levels return to normal (Lee & Marsharani, 2012). In the state of Ohio, an
advanced practice registered nurse with a certificate to prescribe (CTP) may prescribe Atenolol
and Propranolol (The Ohio Board of Nursing, 2014).
Anti-thyroid medications, Popylthiouracil (PTU) and Methimazole, are also considered
when treating thyroid storm. PTU and Methimazole are considered hormone synthesis blockers
(Huecker & Danzl, 2011). PTU is used because it prevents the conversion of T3 to T4 (Lee &
Marsharani, 2012). Both PTU and Methimazole can only be given orally, via nasogastric tube,
or rectally (Huecker & Danzl, 2011). A rare side effect of PTU and Methimazole is
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agranulocytosis and therefore routine complete blood cell counts should be taken. In the state of
Ohio, an advanced practice registered nurse with a CTP may prescribe PTU and Methimazole
(The Ohio Board of Nursing, 2014).
Lugol’s solution can also be administered during a thyroid storm. Lugol’s solution is a
saturated solution of potassium iodide (Weiss & Refetoff, 2005). It acts by stabilizing the
thyroid hormones in addition to the anti-thyroid drug regimen. The administration of antithyroid medications one hour prior to Lugol’s solution is recommended in order to prevent new
hormone synthesis and further exacerbation of the thyroid storm (Weiss & Refetoff, 2005). T3
levels should return to normal within one to five days following administration of anti-thyroid
medications and Lugol’s solution (Weiss & Refetoff, 2005).
Corticosteroids also play a role in the treatment of thyroid storm (Hampton, 2013). Like
Propanolol, corticosteroids block the conversion of T4 to T3 further decreasing the T3 levels.
Corticosteroids also aid in the treatment of adrenal insufficiency, a complication of thyroid storm
(Hampton, 2013). In the state of Ohio, an advanced practice registered nurse with a CTP may
prescribe Corticosteroids (The Ohio Board of Nursing, 2014).
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Case Study 2
1. What is the most appropriate next step in this patient’s diagnostic evaluation? Provide
rationale for your answer.
A. Contrast-enhanced CT scan of the brain
B. Magnetic Resonance Imaging (MRI)
C. Lumbar Puncture (LP) with cerebrospinal fluid
D. Electroencephalogram
E. No further diagnostic testing
A computed tomography (CT) scan is ordered on patients to assess and rule-out
intracranial hemorrhage, skull fractures, and distinguish between a hemorrhagic and ischemic
stroke (Tintinalli et al., 2011). A CT scan previously ordered in this case scenario was negative
for intracranial hemorrhage, hydrocephalus, or other abnormalities. Therefore, it would be in the
best interest of the patient not to re-order the test in order to prevent more radiation exposure
(Tintanalli et al., 2011).
An MRI could be considered in patients with an acute cerebrovascular accident, spinal
cord compression, hip fracture, cerebral venous sinus thrombosis, and carotid and vertebral
artery dissection (Tintanalli et al., 2011). An MRI is a good diagnostic tool for tissue
discrimination and it can visualize bones, ligaments, tendons, the heart, vessels, and solid
abdominal pelvic organs well (Tintanalli et al., 2011). Though an MRI is a great test for many
diagnoses, in this patient’s case a lumbar puncture would be a better diagnostic test. Since the
patient is admitted for probable bacterial meningitis, a lumbar puncture would be a more suitable
test (Tintanalli et al., 2011).
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An electroencephalogram (EEG) is useful to patients in critical care settings for
monitoring brain function post cardiac arrest, detecting ischemia, and monitoring treatment of
epilepsy (Winn, 2011). In patients with recent possible seizure activity, an EEG is particularly
useful in diagnosing seizures as well as monitoring the progress of a patient’s treatment (Winn,
2011). However, this patient would not require an EEG due since the patient is without seizure
activity at this time (Winn, 2011).
Recommendations for initial testing in patients with suspected meningitis include blood
cultures and a lumbar puncture (Chaudhuri et al., 2008; IDSA, 2004). A lumbar puncture is
recommended initially in order to rule-in the diagnosis of bacterial meningitis and in order to
treat with proper antibiotic therapy. Morbidity and mortality increase if there is delay in therapy
for patients with bacterial meningitis (Chaudhuri et al., 2008). Therefore, it is imperative that
patients have a lumber puncture performed early. The patient in this case study would require a
lumber puncture as the next diagnostic test of choice (IDSA, 2004).
2. Which of the following is this patient’s most likely diagnosis? Provide rationale for your
answer.
A. Viral Meningitis
B. Fungal Meningitis
C. Bacterial Meningitis
D. Mycobacterial Meningitis
E. Noninfectious Meningeal Irritation
The patient’s most likely diagnosis is bacterial meningitis. The diagnosis can be made
based on the patient’s physical symptoms and laboratory findings. First, the patient presents
with a headache, confusion, neck stiffness, and a temperature of 100.9 degrees Fahrenheit. All of
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these symptoms should point the nurse practitioner towards a possible meningitis diagnosis
(Roos & Brosch, 2012). The next piece of the diagnosis comes from the results of the lumbar
puncture. The patient has an opening pressure of 270 mmH20, a white blood cell count of 1,050
cells/mcL, and a protein level of 81 mg/dL. The opening pressure reading of 270 mmH20
signifies an elevated pressure in the cerebral spinal fluid (CSF) that can be correlated with
inflammation (Putz et al., 2013). A patient with an opening pressure >180 mmH20 correlates
with a patient who has bacterial meningitis (Chin-Hong & Guglielmo, 2014). The patient’s
white blood cell count in her cerebral spinal fluid (CSF) is elevated placing the patient at risk for
either viral or bacterial meningitis. The white blood cells found in the CSF are predominately
neutrophils. Because of the predominance of neutrophils, the patient most likely has bacterial
meningitis (Chin-Hong & Guglielmo, 2014).
The patient’s protein level is also elevated, placing the patient at risk for bacterial
meningitis. The patient’s protein level is 81 mg/dL. Protein levels found in CSF >80 mg/dL is
diagnostic for bacterial meningitis as well as all other forms on meningitis. The patient’s blood
glucose level from the CSF is elevated at 121 mg/dL making the glucose level inconsistent with
a certain type of meningitis (Chin-Hong & Guglielmo, 2014). The serum blood glucose is also
elevated at 307 mg/dL. Using the elevation in both blood glucose levels, the serum to CSF/blood
glucose ratio can be calculated. This patient’s ratio is 0.39. A ratio that is <0.4 is considered
diagnostic for bacterial meningitis (Roos & Brosch, 2012).
In summary, the patient is considered to have bacterial meningitis based on the CSF
levels. First, the white blood cell count is elevated with the majority of the cells being
neutrophils. Secondly, the opening pressure is elevated revealing inflammation. Third, the
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protein level is elevated. Finally the CSF/serum glucose ratio is <0.4 (Chin-Hong & Guglielmo,
2014; Roos & Brosch, 2012).
3. Based on the gram stain, which of the following antibiotic regimens is the most
appropriate in this patient? Provide rationale for the answer.
A. Penicillin G
B. Ceftriaxone
C. Ceftriaxone and Vancomycin
D. Ampicillin and Cefotaxime
E. Cefepime
In patients 50 years of age or older, the most common pathogens for acute bacterial
meningitis are Neisseria meningitidis, Streptococcus pneumoniae, Listeria monocytogenes, and
gram-negative bacilli (Chin-Hong & Guglielmo, 2014). The patient’s gram-stain revealed grampositive cocci in pairs with many polymorphonuclear leukocytes and a few mononuclear
leukocytes (Chin-Hong & Guglielmo, 2014). Neisseria meningitides is considered to be a gramnegative microbial (Chin-Hong & Guglielmo, 2014). Listeria monocytogenes is a microbial seen
with gram-positive rods. Finally, Streptococcus pneumoniae is considered a microbial with
gram-positive cocci (Chin-Hong & Guglielmo, 2014).
Streptococcus pneumoniae is considered the probable microbial in this case study. The
recommended treatment for patients with meningitis caused by Streptococcus pneumoniae is
Vancomycin and a third generation cephalosporin (Infectious Disease Society of America
[IDSA], 2004). Of the choices given, Vancomycin and Ceftriaxone should be ordered to treat
the patient’s bacterial meningitis (IDSA, 2004). Once the pathogen has truly been identified as
Streptococcus pneumoniae, the patient can be switched to Penicillin G (Chin-Hong &
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Guglielmo, 2014; IDSA, 2004). Intravenous Vancomycin would be ordered at 15 mg/kg/dose
every eight hours and intravenous Ceftriaxone would be ordered one gram every 24 hours (ChinHong & Guglielmo, 2014). In the state of Ohio, a nurse practitioner with a certificate to
prescribe can prescribe Vancomycin and Ceftriaxone (The Ohio Board of Nursing, 2014).
4. Complete the following table. Provide references at the end of the table.
Measurement
Normal
Bacterial
Meningitis
Aseptic
Meningitis
(Viral)
Opening
Pressure
(mmH20)
WBC’s
70-180
mmH20
>180
mmH20
Slightly
elevated
0-5
lymphocytes
200-20,000
cells/mcL
(neutrophils
predominate)
<45mg/dL
25-2,000
cells/mcL
(mostly
lymphocytes)
Normal of
Low
>50 mg/dL
Granulomatous
Meningitis
(Mycobacterial,
Fungal)
Moderately
elevated
100-1,000
cells/mcL
(mostly
lymphocytes)
<45 mg/dL
Spirochetal
Meningitis
Normal to
slightly
elevated
100-1,000
cells/mcL
(mostly
lymphocytes)
Normal
45-85 mg/dL
Glucose
(mg/dL)
15-45 mg/dL
> 50 mg/L
>50 mg/dL
>50 mg/dL
Protein
(mg/dL)
Table 1 Adapted from (Chin-Hong & Guglielmo, 2014). Common problems in infectious
diseases & antimicrobial therapy. In Papadakis & McPhee, Current Diagnosis and Treatment.
New York, NY: McGraw Hill.
5. Should this patient receive adjuvant therapy with dexamethasone? Explain your answer.
Any patient with suspected bacterial meningitis should receive dexamethasone treatment
(Infectious Disease Society of America [IDSA], 2004). The administration of Dexamethasone
has shown to affect morbidity and mortality. Dexamethasone, a steroid, aids in the decrease of
meningeal inflammation (Chaudhuri et al., 2008). Administering dexamethasone to patients with
bacterial meningitis is said to decrease cerebral edema, decrease intracranial pressure, stabilize
cerebral blood flow, and decrease cerebral vasculitis (IDSA, 2004).
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The European Federation of Neurological Sciences has written the most recent
guidelines on bacterial meningitis (Chaudhuri et al., 2008). Dexamethasone is recommended in
the treatment of bacterial meningitis in order to decrease the risk of subarachnoid inflammation
and blood brain barrier inflammation permeability (Chaudhuri et al., 2008). Dexamethasone is
said to work only if given prior to initiation or in co-commitment administration of antibiotic
therapy (Hessen, Baustian, Opal, Asad, & Wijdicks, 2011). The recommended dose of
Dexamethasone is 10 mg every six hours intravenously for four days. In the state of Ohio, an
advanced practice registered nurse with a CTP may prescribe Dexamethasone (The Ohio Board
of Nursing, 2014).
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