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NR511 Week 6 Case Study Part 2-2022

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NR511 Week 6 Case Study Part 2-2022 Case Study Part 2 1. What is your primary diagnosis for this patient as the cause for the CC of fatigue? (support your decision for your diagnosis with pe... rtinent positives and negatives from the case) My primary diagnosis for this patient’s chief complaint of fatigue is hypothyroidism. This diagnosis would be made based on the patient’s history, subjective, and objective findings. Common signs and symptoms of hypothyroidism include generalized weakness, fatigue, weight gain, cold intolerance, constipation, dry skin, dry and coarse hair, thickened nails, muscle cramps, and depression (Dubbs & Spangler, 2014). These signs and symptoms are also pertinent positive findings in this case study. Objective findings include her elevated TSH level at 6.770 uIU/ml, and low free T4 level at 0.62 ng/dl. A TSH level above 4-5 mU/L can confirm the diagnosis of hypothyroidism (Epocrates, 2019). FT4 measurements help determine whether the patient has primary or secondary hypothyroidism. Primary hypothyroidism is defined by an elevated TSH levels and a decreased FT4 that is under 0.7ng/dL (Epocrates, 2019). However, pertinent negative findings include no family history of autoimmune disorders, lack of thyrotoxic medication usage, and no enlargement of the thyroid upon palpation (Dubbs & Spangler, 2014). 2. Identify the corresponding ICD-10 code. The corresponding ICD-10 code for hypothyroidism is E03.9 (Centers for Medicare & Medicaid Services, 2018). 3. Provide a treatment plan for this patient's primary diagnosis which includes: At this time, I would prescribe the following medications: Levothyroxine 25 mcg tablet Disp: #30 Sig: Take one tablet PO QAM CONTINUED........... [Show More]

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