HYPOTHYROIDISM

A 45 years Female patient was admitted in female medical ward with IP number 1394538 on
02/01/2018. CHIEF COMPLAINTS: C/O facial puffiness since 1 month.

PAST MEDICATION HISTORY: No H/O any significant any medication in the past.
PERSONAL HISTORY AND HABITS: Non-smoker, Non-alcoholic, married with not
known allergies.
HISTORY OF PRESENT ILLNESS: H/O swelling in front of neck for 2 months, myalgia,
increased tiredness, hoarseness of voice and headache. H/O Orthopnoea, pain in cheek. PAST
MEDICAL HISTORY: No H/O DM, HTN. Bike accident 7 years back.

VITALS - BP(mm of Hg) 110/60 120/80 110/80 120/70 120/80

PR (bpm) 80/min 82/min 78/min 72/min 80/min
RR (bpm) 22/min 21/min 24/min 24/min 22/min
TEMP (f) 98.6 98.5 98.4 98.2 98.6

GENERAL EXAMINATION: Patient was conscious, Oriented. SYSTEMIC

EXAMINATION D1 D2 D3 D4 D5 CVS S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+) S1,S2 (+)
RS NAD NAD NAD NAD NAD CNS NFND NFND NFND NFND NFND GIT (P/A) Soft
Soft Soft Soft Soft SYSTEMIC EXAMINATION:

PARAMETER OBSERVED VALUE NORMAL VALUE

Hemoglobin 9.5 g/dl 14-17g/dl
ESR 42 mm (5-20mm )
Platelets 2.82 cells/mm3 (1.0-4.5 cells/mm3 )
FBS 87 mg/dl( 60-110mg/dl )
Blood Urea Nitrogen 23 mg/dl (7 - 20 mg/dl)
Serum Creatinine 0.7 mg/dl( 0.5 - 1.4 mg/dl)
T3 0.17ng/ml (0.8-1.6ng/ml )
Total T4 0.6µg/dl (4.2-12 µg/dl )
TSH 134.94 µIU/Ml( 0.5 - 4.70 µIU/mL)
LAB INVESTIGATIONS: DIAGNOSIS: Hypothyroidism
MEDICATION
Tab. Otilonium bromide 40mg P/O BD
Tab. Ranitidine 150mg P/O BD
Tab. Levothyroxine 150mcg P/O OD
Tab. Ferrous sulfate 300mg P/O OD
Tab. Calcium 500mg P/O OD
Inj. Diclofenac 2ml/75mg IM BD
Tab. Norfloxacin 400mg P/O BD
NURSING DIAGNOSIS
 Activity intolerance related to fatigue and depressed cognitive process.
 Risk for imbalanced body temperature related to cold intolerance.
 Constipation related to depressed gastrointestinal function.
 Ineffective breathing pattern related to depressed ventilation.
 Disturbed thought processes related to depressed metabolism and altered
cardiovascular and respiratory status.
NURSING INTERVENTION

 Promote rest. Space activities to promote rest and exercise as tolerated.

 Protect against coldness. Provide extra layer of clothing or extra blanket.
 Avoid external heat exposure. Discourage and avoid the use of external heat
source.
 Mind the temperature. Monitor patient’s body temperature.
 Increase fluid intake. Encourage increased fluid intake within the limits of fluid
restriction.
 Provide foods high in fibre.
 Manage respiratory symptoms. Monitor respiratory depth, rate, pattern, pulse
oximetry, and ABG.
 Pulmonary exercises. Encourage deep breathing, coughing, and use of incentive
spirometry.
 Orient to present surroundings. Orient patient to time, place, date, and events
around him or her.
Discharge and Home Care Guidelines

At the completion of the home care instruction, the patient or caregiver will be able to:

 Medication compliance. State that compliance to medical regimen is life-long.

 Cold intolerance. State the need to avoid extreme cold temperature until condition
is stable.
 Follow-up visits. State the importance of regular follow-up visits with health care
provider.
 Weight reduction. Identify strategies for weight reduction and prevention of
constipation such as high-fiber, low-calorie intake and adequate fluid intake.