Common Symptoms that the FNP
1. What are common symptoms that the FNP may find with B12 deficiency that would not be seen with Iron deficiency anemia or anemia of chronic disease?
2. *POST FROM PEER*
Chief complaint, PMHx, Demographics, PSHx, allergies, lifestyle, HPI
CC: fatigue and muscle weakness.
HPI: C.W is a 28-year-old female and presents to the clinic complaining of increasing fatigue and muscle weakness for the past month. C.W. is going through a lot of stress with trying to balance family, work, and school life that lately she is having less energy to perform her daily tasks. C.W. had strep throat in the past month in which she received antibiotics through primary. C.W. states that she has problems sleeping throughout of the night and do not wake up feeling rested. Patient denies snoring, SOB, chest pain, constipation and melena.
PMH: Type 1 diabetes
Allergies: NKA
Lifestyle: high stress and demanding work and school life
Social history: Denies smoking and drinking alcohol
Associated risk factors/demographics that contribute to the chief complaint and differential diagnoses
The risk factors that contribute to the chief complaints is stressful lifestyle and recent illness that placed body under greater stress. Major stresses like acute illnesses places patient at risk for developing adrenal insufficiency (Arlt et al., 2020). Also, a current medical condition of type 1 diabetes is a risk factor. A patient with type 1 diabetes is also at a greater risk of developing adrenal insufficiency because type 1 diabetes is a part of the autoimmune polyendocrine syndromes (Vinci et al., 2021). It not uncommon for autoimmune disease to run together meaning if a patient have one autoimmune condition then a patient can have another.
Three common differential diagnoses represented by the CC including pathophysiology and rationale in the identified body system i.e., if pulmonary was your body system than a chief complaint could be persistent cough and three pulmonary differentials.
Three common differentials represented by the chief complaint is primary adrenal insufficiency, Hashimoto thyroiditis and hypothyroidism. Hashimoto thyroiditis and primary hypothyroidism though related to hypothyroid state are different conditions and have different approach to therapy. Hypothyroidism refers a problem in the thyroid gland and Hashimoto involves problems with the immune system developing antibodies to attack thyroid gland. Hashimoto thyroiditis is an autoimmune condition. Similarly, to adrenal insufficiency. Primary Adrenal insufficiency also known as Addison’s disease is an autoimmune condition that occurs when the adrenal glands cannot produce an adequate number of hormones. The rationale for choosing these three differential diagnoses because each condition can lead to hormonal imbalances that manifest in symptoms of fatigue and muscle weakness.
Discuss how the three differential diagnoses differ from each other in: occurrence, pathophysiology and presentation (NOTE: Simply listing the diagnoses and their occurrence, pathophysiology and presentations separately does not confer an understanding of how they differ. Your discussion should compare and contrast these items against each other among the three differentials chosen);
Hashimoto thyroiditis and hypothyroidism are believed to be the same condition, but they are different. Hashimoto thyroiditis involves the formation of antithyroid antibodies that attack the thyroid tissue, causing progressive fibrosis (Mincer & Jialal, 2017). Hashimoto thyroiditis is an autoimmune systemic response. Hashimoto thyroiditis can lead to a hypothyroid state, but it also can have a gradual thyroid failure and thyroid hormones may not be depleted. Primary Hypothyroidism is permanent loss of thyroid tissue that inhibits ability to adequately produce thyroid hormones. Primary adrenal insufficiency is autoimmune response involving the destruction of the adrenal cortex leading to decreased aldosterone and cortisol production due to diminished gland function. Unlike hypothyroidism and Hashimoto thyroiditis, primary adrenal insufficiency involves the adrenal glands and not the thyroid glands. Clinical presentation of adrenal insufficiency, Hashimoto thyroiditis, and hypothyroidism involves fatigue, muscle weakness, hair loss, sleep disturbances and decrease sexual drive. However, adrenal insufficiency can be distinguished from the other differentials if the patient is exhibiting weight loss and diarrhea rather than weight gain and constipation. Primary adrenal insufficiency will also have low levels of cortisol levels. Hashimoto thyroiditis will have elevated thyroid antibodies with low or normal TSH levels. Primary hypothyroidism will have elevated TSH and low T4 hormones.
Relevant testing required to diagnose/evaluate severity of the three differential diagnoses; and Review of relevant National Guidelines related to the Diagnosis and Diagnostic testing for these diagnoses
Adrenal insufficiency may not be diagnosed as early in primary care compared to Hashimoto thyroiditis and hypothyroidism. However, it is important to evaluate for primary adrenal insufficiency when patients present with symptoms that can be result of hormonal changes. The endocrine society recommends that patients should undergo a blood test to measure levels of adrenocorticotropic hormone (ACTH), renin, aldosterone, and cortisol in the early AM to diagnose primary adrenal insufficiency and if left untreated then lead to medical emergency of adrenal crisis (Bornstein et al., 2017). If the cortisol level is low and ACTH is high, then the patient has primary adrenal insufficiency. Hypothyroidism is determined by TSH levels in relation to T4 hormones. The patient will need blood test for TSH, T4, anti-thyroid peroxidase, antithyroglobulin. If the antibodies are positive, then the patient has Hashimoto thyroiditis. If TSH is elevated and T4 is low, then the patient will be diagnosed with primary hypothyroidism. If TSH is elevated with a positive antibody, then the patient has hypothyroid state due to Hashimoto thyroiditis. However, it is also possible for patients to have a positive thyroid antibody (Hashimoto thyroiditis) but destruction to the thyroid is slow and has not caused enough damage to need hormone replacements.
References:
Arlt, W., Baldeweg, S. E., Pearce, S. H., & Simpson, H. L. (2020). Endocrinology in the time of COVID-19: management of adrenal insufficiency. European journal of endocrinology, 183(1), G25-G32.
Bornstein, S. R., Allolio, B., Arlt, W., Barthel, A., Don-Wauchope, A., Hammer, G. D., … & Torpy, D. J. (2017). Diagnosis and treatment of primary adrenal insufficiency: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 101(2), 364-389.
Mincer, D. L., & Jialal, I. (2017). Hashimoto thyroiditis. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK459262/#:~:text=The%20pathophysiology%20of%20Hashimoto%20thyroiditis,late%20in%20the%20disease%20process (Links to an external site.).
Vinci, F., d’Annunzio, G., Napoli, F., Bassi, M., Montobbio, C., Ferrando, G., & Minuto, N. (2021). Type 1 Diabetes and Addison’s Disease: When the Diagnosis Is Suggested by the Continuous Glucose Monitoring System. Children, 8(8), 702
