Assessment History: Chronic Acoustic Trauma
A 39-year-old male presents with a partial hearing loss. The first symptoms of deafness appeared a week ago when he returned home after a shift at a construction site where he works. He has been a construction worker for over 5 years.
S: Patients report the recurring feeling of pressure in the ears and head (which appear mainly after working hours), fatigue, and inability to concentrate. He does not wear hearing protection at work regularly and, thus, is often exposed to loud noise. The patient reports excess stress and mood problems. He denies any chronic diseases, yet complaints regarding frequent headaches and elevated blood pressure (BP). He denies tinnitus, acute and chronic infections, interaction with toxins, antibiotic treatment, and the presence of hearing loss in the family history.
O: BP − 125/95 (Abnormal), temperature − 100.2 (Normal), pulse − 105 (Normal). Psychiatric assessment: the patient is slightly disoriented, and his thought process is incoherent. The mood is neutral. HEENT assessment reveals no eye or ear lesions and masses, no septal deviation in the nose. The neck is supple, with full ROM. No cervical lymphadenopathy and occipital nodes are observed. Endoscopy does not reveal any ruptures in the tympanic membrane.
A: The main diagnosis is chronic acoustic trauma. The differential diagnosis is progressive neurosensory deafness associated with such systemic diseases as arterial hypertension (Agarwal, Mishra, Jagade, Kasbekar, & Nagle, 2013). The nursing diagnosis: altered sensory perception.
P: The following treatment and follow-up measures are suggested for the patient:
- Refer to speech threshold testing as it may help identify the distance at which he can currently perceive and differentiates vocal noises at 80-90 dB, 50-60 dB, and 30-35 dB. Normally, at the conversational volume (50-60 dB), the speech is heard at a distance of about 20 meters, while whispers (30-35 dB) − at an approximately 5-meter distance (Schoepflin, 2012). Patients with hearing loss usually perceive the speech at smaller distances.
- Refer to an otolaryngologist.
- Within one month after the first referral, obtain ≥2 readings of BP to diagnose hypertension in him (Rubenfire, 2017). Normal BP is <120/<80 mm Hg; increased BP − 120-129/<80 mm Hg; hypertension stage 1 − 130-139/80-89 mm Hg, and hypertension stage 2 − ≥140/≥90 mm Hg (Rubenfire, 2017).
- Since there are not treatment methods that could help cure hearing loss in modern medical practice, it is essential to educate the patient about hearing protection methods and emphasize their significance in the prevention of irreversible changes. Common prevention methods include the use of anti-noise protective equipment and reduction of noise exposure time.
- In the case of identified severe hearing loss, technological hearing assistance can be recommended for the patient.
Assessment History: Hypothyroidism
A 45-year-old female presents with a 2-week history of focal hair loss. Initially, the increased diffuse hair loss started three months before due to a few episodes of severe work-related stress.
S: Additional subjective symptoms include decreased appetite, apathy, drowsiness, fatigue, and depressive mood. The patient reports a slight weight gain in a few past months and increased sensitivity to cold. She denies the presence of autoimmune diseases of the thyroid gland in the anamnesis, surgical interventions on the thyroid gland, the history of treatment with radioactive iodine and antithyroid medications, infertility, and irregular menstrual cycle.
O: BP − 122/76 (Normal), temperature − 97.4 (Low), pulse − 101 (Normal).
The posterior palpation of the thyroid gland is performed in the following way: the practitioner’s fingers are located above the right sternocleidomastoid muscle and move the trachea in the medial direction; the pads of the fingers of the other hand palpate the left lobe of the gland while the patient tilts her head slightly in the direction of palpation to ease the tension of the neck muscles (Lewis et al., 2017). During the anterior palpation, by using the back surface of the three fingers, the practitioner displaces the sternocleidomastoid muscle and the underlying lobe of the gland anteriorly and medially; the fingers of the other hand probe the gland tissue while the patient is swallowing (Lewis et al., 2017).
On palpation, lateral lobes of the thyroid gland are not determined; the isthmus is in the transverse position, smooth, dense, elastic, and homogeneous inconsistency. The palpation is a painless cushion. The width of the isthmus does not exceed the width of the middle finger of the hand. The gland is not soldered to the skin and surrounding tissues. It is easily displaced when swallowing. Head examination reveals such objective visual signs as slight periorbital edema and icterus. During the assessment of the musculoskeletal system, joint stiffness; delayed muscle contraction, and relaxation are observed.
A: The main diagnosis is hypothyroidism because “it is well-known that thyroid hormone is essential for the development and maintenance of the hair follicle” (Vincent & Yogiraj, 2013, p. 57). Moreover, recent research evidence reveals the links between alopecia and hypothyroidism (Vincent & Yogiraj, 2013), and the patient’s thyroid gland is not enlarged as it could be in thyrotoxicosis and hyperthyroidism. However, it is essential to differentiate between the primary and the secondary form of the disease. Nursing diagnoses include imbalanced nutrition and fatigue.
P: The following lab tests, treatment, and education methods should be administered:
- Blood test for hormonal composition. Normally in adults, the serum level of triiodothyronine (T3) equals 80-220 ng/dL, while the level of tetraiodothyronine (T4, thyroxine) is 57–148 nmol/L (Hammami, 2013; Poduval, 2014). In hypothyroidism, these indicators can be significantly reduced. The level of thyroid-stimulating hormone (TSH) is to be identified as well. In the case of primary hypothyroidism when thyroid hormones are constantly lacking, the reflex stimulation of the pituitary gland takes place, and a large amount of TSH is released into the blood. It has a stimulating effect on the thyroid gland forcing it to synthesize more T3 and T4 hormones. In adults of 21-54 years old, expected TSH values are 0.4-4.2 mIU/L (Sofronescu, 2015). In primary hypothyroidism, the TSH level is usually increased while in the secondary form of the disease, it is decreased.
- Refer to ultrasound of the thyroid gland, X-ray, or computed tomography to identify any visual abnormalities.
- Refer the patient to Red Blood Cell Count test to identify the content of erythrocytes (norm 4.1-5.1 million/mL) and hemoglobin (norm 120-140 g/L) in the blood because anemia can develop due to inability of the intestine to absorb iron and vitamin B-12 adequately (Curry, 2015).
- Refer the patient to an endocrinologist.
- Educate her on metabolic changes associated with hypothyroidism, nutritional requirements, and possible changes to the environment, which could alleviate the adverse symptoms such as increased sensitivity to cold. It is important to inform the patient about hormone replacement therapy, as well as risks and benefits associated with it.
References
Agarwal, S., Mishra, A., Jagade, M., Kasbekar, V., & Nagle, S. K. (2013). Effects of hypertension on hearing. Indian Journal of Otolaryngology and Head & Neck Surgery, 65(Suppl 3), 614–618.
Curry, C. V. (2015). Erythrocyte count (RBC).
Hammami, M. B. (2013). Thyroxine.
Lewis, S. M., Bucher, L., Heitkemper, M. M., Harding, M., Kwong, J., & Roberts, D. (2017). Medical-surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Elsevier.
Poduval, J. (2014). Triiodothyronine.
Rubenfire, M. (2017). 2017 guideline for high blood pressure in adults.
Schoepflin, J. R. (2012). Back to basics: Speech audiometry.
Sofronescu, A. G. (2015). Thyroid-stimulating hormone.
Vincent, M., & Yogiraj, K. (2013). A descriptive study of alopecia patterns and their relation to thyroid dysfunction. International Journal of Trichology, 5(1), 57–60. Web.