HPI:

Sherrie Masterson is a 24-year-old female with a history of hypothyroidism, with a 3-month history of persistent vomiting, followed by the gastroenterology service; she is thought to have gastritis based on a recent upper endoscopy report. She continued to have vomiting and weight loss, so she presented to the emergency department and was found to be hypotensive, tachycardic, and cachectic. Her serum labs demonstrated hyponatremia, normal potassium levels, and a random cortisol level that was very low. Thyroid-stimulating hormone was normal. CBC was unremarkable, UA was normal, and a negative pregnancy test. Serum glucose, liver function tests, and renal function were normal. You are the AGACNP who diagnoses her with Addison’s disease and admits her to the hospital for further workup and treatment.

1Medical History

  • Hypothyroid
  • Gastritis

2Social History

  • Smokes 2-3 cigarettes socially on weekends
  • No recreational drug use
  • ETOH-none
  • Single, no children
  • Employed as hairdresser

3Medications

  • Protonix 40mg po daily
  • Levothyroxine 100 mcg po daily

4Allergies

  • None

Exam

  • Vitals:
    • Pulse 104
    • Resp 18
    • BP 96/50
    • SpO2 98%
    • Temp 37 °C (98.6 °F)
    • 65kg
    • 5’6”
  • Constitutional: Alert, no acute distress. Thin.
  • HEENT: Head is normocephalic and atraumatic. Eyes without icterus or injection. Mucous membranes pink and dry. Neck is supple, nontender without adenopathy. No JVD. No meningismus.
  • Resp: Lungs clear to auscultation bilaterally without wheezes, rales, or rhonchi. No increased work of breathing.
  • Cardiovasc: S1S2 without murmur, rub, or gallop. Regular rate and regular rhythm. Pedal pulses 2+ and equal. No edema.
  • Abd/GI: Soft, non-tender, nondistended. No masses.
  • Skin: Pink, warm, dry. No rashes or bruising.
  • Ext: Movement all extremities without limitation.
  • Back: Normal inspection. Nontender.
  • Psych: Affect normal. Appropriate attention, cooperation.
  • Neuro: Alert and oriented x 4. No focal motor or sensory deficits.

Week 10 Case Study Assignment 1: Endocrine Decision Making

Clinical Decision-Making Questions

  1. You would like to order a medication to replace cortisol in this patient. What medication would you order? Write out the order including the pharmaceutical agent, dose, route, and duration. Why have you selected this medication in this situation? Justify your selection over alternatives. What classof medication are you choosing and why? Explain why this medication and route was chosen over other options. Include the pharmacodynamic action of the medication you have chosen in comparison to the other options you mentioned. Include either a research article or evidence- based guideline that supports your decision-making and selection process. Give rationale and reference your information.
  2. You would like to order a medication to replace aldosterone in this patient. What medication(s)would you order? Write out the order including the pharmaceutical agent, dose, route, and duration. Why have you selected this medication in this situation? Justify your selection over alternatives. What class of medication are you choosing and why? Explain why this medication and route was chosen over other options. Include the pharmacodynamic action of the medication you have chosen in comparison to the other options you mentioned. Include either a research article or evidence-based guideline that supports your decision-making and selection process. Give rationale and reference your information.
  3. What are the potential side effects and/or adverse drug reactions and how should they be managed? Are there any reasons/indications that you would not give these medications? What would you expect that your patient might experience, and what are your worst-case scenarios? If these occur, what would you do?
  4. What are potential drug interactions for this patient and what would your management be if you were concerned about a drug interaction? (Note: This answer may be none.) Don’t just copy and paste drug interactions into this area. What is applicable for this patient?
  5. What is the cost of these medications? What reference was used to obtain this cost information?How does it compare to other options available for this patient? Is it your best option based on cost and effectiveness and indication for this patient?
  6. How would you monitor the efficacy of these medications? Specifically, when would you expect these medications to work? Are there lab tests or other information that you would need to gather to see if these medications are efficacious? How do you know these medications are efficacious?
  7. What are alternative treatment plans should this option fail? Specifically, address what medication, how, and when you would use it.
  8. How would this treatment change if the patient was a pregnant female? Specifically, what category in pregnancy is these medications? How would you approach these medications or alternative medications in this case scenario with a pregnant patient?

 

  1. How would this treatment change if the patient was an 85-year-old male?
  2. Include an APA reference sheet with at least three references, including one evidence-based Internet resource (a URL), and at least one evidence-based research article.