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RESPONSE 1: Prompt # 1, Melina Based on the information provided, it seems that
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Prompt # 1, Melina
Based on the information provided, it seems that Melina has hypothyroidism. Before I start discussing specifics about the condition, I will first acknowledge her concerns and empathize with her because clearly, she has an array of things that are overwhelmingly concerning for her, causing her distress. I will most likely ask her regarding the details surrounding her symptoms and job. Was it her symptoms that caused her to lose her job? Is she stressed from her symptoms or from losing her job or both? Allowing her some time to share or vent her feelings and letting her see that as a provider, I am concerned about her whole being, may help her be more receptive to the information and education I am about to divulge. Hypothyroidism is a common chronic pathological condition of thyroid hormone deficiency – thyroxine (T4) and triiodothyronine (T3). It is one of the most common diseases worldwide and it affects women more commonly than men, with its incidence increasing with age, peaking at around age 30 to 50 (Chiovato, Magri, Carlé, 2019) and Melina belongs to this age group. Hypothyroidism is also common in patients with autoimmune diseases such as T1DM, autoimmune gastric atrophy, and celiac disease (Chiovato, Magri, Carlé, 2019). If left untreated, it can demonstrate a range of symptoms, decrease one’s quality of life, and potentially be fatal in severe cases.
Hypothyroidism results from the low levels of thyroid hormones and is classified as primary, secondary, tertiary, and peripheral based on the etiology. Primary is due to the inability of the thyroid gland to produce adequate amounts of thyroid hormones, secondary has to do with TSH deficiency resulting from a pituitary gland pathology, tertiary results when there is a defect within the hypothalamus leading to thyrotropin-releasing hormone deficiency, and peripheral is a permanent congenital hypothyroidism due to defects in the thyroid hormone metabolism (Chaker, et. al, 2017). We know that Melina has hypothyroidism due to her TSH level of 8 (normal is around 0.5-5.0 mU/L). TSH levels indicate the thyroid gland function. When levels are high, it indicates that the thyroid is not making enough thyroid hormones. Alternatively, when the TSH is low, it means that the thyroid is making too much thyroid hormone. I would also explain to her that adding a free T4 blood test will aid in determining the type of hypothyroidism she has. The free T4 measures unbound thyroid hormones that can affect the body (American Thyroid Association, 2021). When free T4 levels are low, coupled with high TSH, it indicates primary hypothyroidism, whereas when free T4 levels are low, coupled with low TSH, it indicates secondary hypothyroidism. Additionally, for the purpose of treatment, knowing the free T4 levels can help determine whether Melina has overt or subclinical hypothyroidism. Overt is characterized by elevated TSH and low T4 while subclinical is a milder form where only the TSH in abnormal and there is controversy whether this should be treated in non-pregnant adults (Chiovato, Magri, Carlé, 2019).
It is necessary to make Melina aware that upon diagnosis of hypothyroid based on its clinical features along with biochemical confirmation of overt hypothyroidism, this serves as an indication for treatment. Lifelong monotherapy using levothyroxine will be initiated, unless the reason for the hypothyroidism is due to transient forms of thyroiditis, iodine deficiency, or drugs where appropriate actions to correct the cause of insult can be addressed and subsequently relieve symptoms and correct thyroid levels (Chaker, et. al, 2017). The goal of levothyroxine treatment is to reduce symptoms and prevent long-term complications. Untreated hypothyroidism can manifest with symptoms such as weight gain, fatigue, poor concentration, depression, menstrual irregularities, lethargy, cold intolerance, constipation, and dry skin (Patil, Rehman, & Jialal, 2021), many of which are complaints shared by Melina. Additionally, I would make her aware that untreated and undertreated cases can also cause more serious complications such as myxedema coma. It is also important to let her know that levothyroxine will be taken daily and dosed based on the presence of coexisting cardiac disease, etiology, and severity of hypothyroidism (Chaker, et. al, 2017). Doses of the medication will be adjusted based on TSH levels. Levothyroxine has a long half-life of about one week, and TSH levels will be measured every four to six weeks after initiation of therapy and after every dosage change. Once levels are stable, then TSH levels will be monitored every twelve months. It is also important for her to know that over the years, replacement dose may require adjustment as well based on disease progression and comorbidities (Chiovato, Magri, Carlé, 2019). Moreover, it is also crucial that she is educated about other conditions that make people prone to hypothyroidism and that screening tests for such may be necessary to ensure underlying causes are addressed. Giving her all the details regarding treatment scheduling and follow up is extremely essential to help ensure adherence to the treatment regimen because symptom relief is dependent on her achieving normal thyroid levels which should subsequently resolve most, if not all, of her symptoms. Lastly, it is also important that she knows that resolution of her concerns and symptoms may not be apparent immediately and may take some time, therefore, it would be prudent to help her find other ways to cope in the meantime.
Jackson is a 37-year-old male with a 10-year 1 pack per day smoking history with no avail in OTC smoking cessation products. He is now asking for a prescription option. In the United States cigarette smoking is responsible for more than 480,000 deaths per year, this is 1,300 deaths per day with on average smokers living 10 years less than nonsmokers (CDC, 2020). Smoking will increase the risk of lung disease, heart disease, strokes, COPD, and other respiratory illnesses such as tuberculosis. It is also known that smoking will increase the risk of immune system issues, eye problems, and erectile dysfunction in males (CDC, 2020). With all these known facts though, in 2018, 55.1% of all smokers have attempted to quit smoking in the past year, with 7.5% successful in smoking cessation (CDC, 2020).
As a health care practitioner we should be assessing the patient’s status on smoking – whether or not they partake. According to Sealock & Sharma (2021), The US Preventive Services Task Force (USPSTF) recommends using the 5 As: 1. Ask about smoking (smoking status should be documented with every visit) 2. Advise to quit (Use clear personalized messages to the patient) 3. Assess willingness to quit (Patients who are not willing to quit should receive motivational interventions) 4. Assist in quitting (Patients who are willing to quit should set a date to quit) 5. Arrange follow-up and support (Behavioral interventions alone or in combination with pharmacotherapy improve the achievement of smoking cessation and have seen to be both conducive to smoking cessation therapy). As we know Jackson is motivated to quit smoking we should continue on with both behavioral and pharmacological interventions.
Woo & Robinson (2019) state, a review of the physiological and psychological processes of addiction will assist the health-care provider in understanding the rationale for pharmacological intervention. Once we assess both the physiological part of Jackson, such as labs, diagnostic tests such as chest x-rays, and history and physical, we should also assess his psychological process as they tie in closely. Smoking is related to psychological process because it deals with our addiction center and nicotine is the culprit for such.
As proposed before a behavioral therapy is recommended with pharmacological therapy. Behavioral therapy can include: Self-help materials, telephone counseling, and in-person counseling. These interventions can see an increased rate of smoking cessation from 5-11% to 7-13% increase (Sealock & Sharma, 2021). Pharmacological therapy can begin from OTC means first. As we have assessed, Jackson has tried nicotine lozenges and gum with no effect. We can try the next step which would be nicotine replacement therapy (NRT). Since the gum and lozenges are a part of NRT the nicotine patch would be the next best choice. It has been seen that a combination of the slow release of the nicotine patch with a quick release of gum/lozenge to be effective for nicotine withdrawals (Sealock & Sharma, 2021). It is important to mention to Jackson that NRT is not going to provide the same nicotine peak levels but more of a tapering means to wean off cigarettes (Woo & Robinson, 2019). For transdermal nicotine patches we educate Jackson to apply one patch of the 21 mg/d to the hairless part of the arm for 24 hours. We choose 21 mg/d due to smoking >10 cigarettes/day and use every day for 6 weeks upon waking up. From there we slowly taper down the dosage strength to 14 mg/d for 2 wk, and finally 7 mg/d for final 2 wk (Woo & Robinson, 2019).
If Jackson still encounters issues on smoking cessation then we can move onto prescriptive option. The first line choice is Bupropion SR. Bupropion SR is a weak dopamine and norepinephrine inhibitor which is thought to increase available dopamine which helps with smoking cessation (Woo & Robinson, 2019). To educate Jackson we tell him to tell him to start taking the medication 1-2 weeks prior to his quit date, to allow the medication to reach therapeutic levels, and we tell him to take 150 mg daily for 3 days, and then the dose is increased to 150 mg twice a day at least 8 hours apart, avoiding bedtime dosing (Woo & Robinson, 2019). We should also tell Jackson to take bupropion concurrently with NRT to maximize smoking cessation. Therapy should be concluded within 7-12 weeks (Woo & Robinson, 2019). We should explain to Jackson side effects include: Suicidal ideations (as bupropion is an antidepressant), insomnia, dizziness, and dry mouth. Care in dosing should be evaluated as renal and hepatic issues can occur. Bupropion is contraindicated with history of strokes and MAOI medications (Woo & Robinson, 2019). It’s always important to have a follow-up with Jackson in order to assess effectiveness in behavioral, pharmacologic, and psychologic therapy during and after smoking cessation treatments.
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