I. INTRODUCTION

Definition

Distinction

Learning

II. PATIENT’S PROFILE

Physical Assessment

III. NURSING MANAGEMENT

Assessment Diagnosis

SOAPIE

SOAPIE

Patient’s Name:         Lubguban, Anacleto                 Ward 3B, Semi-Private,  Bed PN2

Date: February 2, 2006                                  Time: 9:00 A.M.                                     Diet: NPO

FRANCIS ABRAHAM P. MILLOREN     /    KENDRICK DILLA CAÑARES, RN

CNU-CN      CLASS 2008                          /                 Clinical Instructor

SOAPIE

Patient’s Name:         Lubguban, Anacleto                 Ward 3B, Semi-Private,  Bed PN2

Date: February 3, 2006                                  Time: 9:00 A.M.                                     Diet: NPO

FRANCIS ABRAHAM P. MILLOREN     /    KENDRICK DILLA CAÑARES, RN

CNU-CN      CLASS 2008                          /                 Clinical Instructor

II. MEDICAL MANAGEMENT

Pathophysiology

Medications

V. BIBLIOGRAPHY

DEFINITION

Hashimoto's Thyroiditis (also called autoimmune or chronic lymphocyctic thyroiditis) is the most common type of thyroiditis. It is named after the Japanese physician, Hakaru Hashimoto, that first described it in 1912.

Thyroiditis is the inflammation of the thyroid gland. Hashimoto's thyroiditis is the most common form of thyroiditis. Hashimoto's Thyroiditis is a type of autoimmune thyroid disease in which the immune system attacks and destroys the thyroid gland. This means that the body can sometimes aim an immune attack, similar to the way it might fight germs or cancer, against its own thyroid gland. When that occurs, white blood cells called lymphocytes can infiltrate into the tissue of the thyroid gland. When doctors remove small amounts of thyroid tissue, either with a needle biopsy or during surgery, pathologists are able to see this infiltration, using microscopes. Blood tests can also demonstrate antibodies against the thyroid gland. The thyroid helps set the rate of metabolism, which is the rate at which the body uses energy. Hashimoto’s stops the gland from making enough thyroid hormones for the body to work the way it should.

An autoimmune disease occurs when the body's immune system becomes misdirected and attacks the organs, cells or tissues that it was designed to protect. About 75% of autoimmune diseases occur in women, most often during their childbearing years.

The thyroid gland is always enlarged, although only one side may be enlarged enough to feel. During the course of this disease, the cells of the thyroid become inefficient in converting iodine into thyroid hormone and "compensates" by enlarging. The radioactive iodine uptake may be paradoxically high while the patient is hypothyroid because the gland retains the ability to take-up or "trap" iodine even after it has lost its ability to produce thyroid hormone. As the disease progresses, the TSH increases since the pituitary is trying to induce the thyroid to make more hormone, the T4 falls since the thyroid can't make it, and the patient becomes hypothyroid. The sequence of events can occur over a relatively short span of a few weeks or may take several years.

In a patient with Hashimoto's Thyroiditis, autoantibodies and the cytotoxic cell mediated immune response work to attack and destroy the patient's own thyroid tissue. This damage to the thyroid gland results in hypothyroidism, or thyroid underactivity. Hashimoto's patients may experience tiredness, forgetfulness, depression, coarse dry skin, slow heartbeat, weight gain, goiter, intolerance to cold or constipation. These symptoms describe a metabolism slowdown, driven by a loss in thyroid hormone production. Hashimoto's Thyroiditis may begin as mild thyrotoxicosis, but can progress to overt hypothyroidism and myxedema.

A Hashimoto's Thyroiditis patient would present the elevated TSH values and possibly low thyroid hormone levels characteristic of hypothyroidism. However, a high concentration of thyroid autoantibodies (TPOAb in particular) is the distinguishing evidence for a diagnosis of Hashimoto's Thyroiditis. Greater than 90 percent of all Hashimoto's Thyroiditis patients are positive for TPOAb. A Radioactive Iodine Uptake Test (RAIU) would also demonstrate a low uptake rate.

Hashimoto’s thyroiditis or Hashimoto’s disease is a member of the family of “auto-immune” diseases such as Rheumatoid arthritis.  These diseases are characterized by an immune system that, for some reason, identifies the patient’s own tissue as being “foreign” or not a normal, natural part of that person’s body.  A good example of this is demonstrated when a patient receives a kidney transplant and the immune system recognizes that this new tissue is, indeed, foreign.  The immune system then makes antibodies to go and attack this “foreign” tissue.  This results in a battle between the antibodies and the tissue perceived as foreign, and this results in inflammation.  In the case of the kidney, it causes a “nephritis”.  In the case of the rheumatoid arthritis patient, the joint capsule is attacked, and this causes an “arthritis”.  In the thyroid it causes a “thyroiditis”.

There are other ways the thyroid gland can become inflamed and a thyroiditis results, but if the inflammation is due to the patient producing antibodies against his or her own thyroid gland, then it is called Hashimoto’s auto-immune chronic lymphocytic thyroiditis…..a big name we simply refer to as Hashimoto’s Disease, and for this discussion we will simply say “chronic thyroiditis”. 

Chronic thyroiditis takes on importance in several ways.  First, years of inflammation can lead to destruction of normal thyroid tissue, which in time can result in low thyroid hormone levels in the blood, or a disorder known as “hypothyroidism”.  This will require treatment with lifelong thyroid medication to insure that the patient always has normal levels of thyroid hormone in the blood stream.

Second, extended periods of inflammation can lead to scarring and fibrosis and sometimes the formation of a round, hard nodule that is very difficult to distinguish from a thyroid tumor or even a thyroid cancer.  These patients will sometimes have to undergo a thyroidectomy for this reason. 

Third, all scar tissue wants to get smaller.  This is called the process of “contracture”.  For example, if you get a 6-inch cut on your leg today, a scar will form.  If you measure that scar next year, lets say, it may only be 5 ½ inches long.  Well, scar tissue in the thyroid gland also wants to get smaller, but the thyroid gland sort of wraps around the windpipe and the esophagus to some degree.  When this scar tissue undergoes contracture it can put pressure on those structures and produce what are called “compression symptoms”, that is, difficulty in breathing or swallowing.  Some patients have actually choked on their food and have required the Heimlich maneuver because of the tightness that has been created.  Others say that they have difficulty in breathing, especially when they lie down.  These patients may require thyroidectomy for relief of these symptoms. 

Fourth, about 30% of our patients with thyroid cancer are also found to have chronic thyroiditis.  This does not mean that if you have chronic thyroiditis that you will be certain to get thyroid cancer, but note is made of this casual relationship.  There are a few voices out there that would recommend that all patients with Hashimoto’s Disease undergo thyroidectomy.  This seems a bit radical and a very large number of patients would undergo unnecessary thyroid surgery.  Close and thoughtful observation by a thyroid specialist seems to be a prudent course of action for patients with chronic thyroiditis.  Surgery can always be recommended if a patient develops a mass or symptoms which require further treatment, with little negative impact on prognosis.  Please remember, I am discussing this topic in general terms for informational use only.  There is no substitute for you and your physician making medical decisions based on your individual and specific case.

Fifth, some patients with chronic thyroiditis may suffer intermittent bouts of hyperthyroidism, as the disease is known to have flare-ups with release of excess quantities of thyroid hormone now and again.  These flare-ups require medical treatment.  Only rarely is surgery required because of failure of this medical treatment.

Sixth, there are rare instances of lymphoma developing within the thyroid gland.  Lymphoma is a cancer of the lymphatic system and can manifest itself in many ways, one way being enlargement of lymphatic tissue or lymph nodes.  In the thyroid gland, this is usually a rapidly growing mass and it is important to distinguish this from a possible anaplastic cancer of the thyroid, which is extremely lethal.  Often these lymphoma patients have long-standing chronic lymphocytic thyroiditis, and the lymphoma is believed by some, to arise in this background of chronic inflammation and irregular cells.

DISTINCTION

The incidence of Hashimoto's thyroiditis seen in practice is unknown but is roughly equal to that of Graves' disease (on the order of 0.3 - 1.5 cases per 1,000 population per year.)(35-37) The disease is 15 - 20 times as frequent in women as in men. It occurs especially during the decades from 30 to 50, but may be seen in any age group, including children. It is certain that it exists with a much higher frequency than is diagnosed clinically, and its frequency seems to be increasing. Family studies always bring to light a number of relatives with moderate enlargement of the thyroid gland suggestive of Hashimoto's thyroiditis. Many of these persons have TG and TPO antibodies, and most are entirely asymptomatic. Inoue et al. found 3% of Japanese children aged 6 - 18 to have thyroiditis(38). In most instances, biopsy revealed focal rather than diffuse thyroiditis.

In addition to overt thyroiditis, roughly 10% of most populations have positive TG and TPO antibody test results(35-37) in the apparent absence of thyroid disease by physical examination. In a classic study of an entire community, Tunbridge et al.(37) found that 1.9 - 2.7% of women had present or past thyrotoxicosis, 1.9% had overt hypothyroidism, 7.5% had elevated TSH levels, 10.3% had test results positive for TPO (microsomal antigen) Ab measured by hemagglutination assay (MCHA), and about 15.0% had goiter. Men had 10 to 4-fold lower incidence of thyroid abnormalities. In a study of children whose parents had history of thyroid disease, Carey et al.(39) found a 24% prevalence of thyroid "abnormalities", including a prevalence of 6.9% abnormal thyroids, and 9.3% with positive TG Ab measured by hemagglutination assay (TGHA) and 7.8% positive MCHA assays. Gordin et al.(35) found that 8% of adult Finns had positive TGHA results, and 26% had positive MCHA results. TSH levels were elevated in 30% of these persons. On the basis of positive antibody titers and elevated TSH levels, 2 - 5% were believed to have asymptomatic thyroiditis. These test results correlate with focal collection of lymphocytes on histologic examination of the thyroid glands(40), are frequently associated with elevated levels of TSH(41), and probably represent one end of a spectrum of thyroid damage. Women with both positive antibody test results and raised TSH levels become hypothyroid at the rate of 5%/year(42). A reasonable approximation of the prevalence of positive antibody tests in women is greater than 10%, and of clinical disease is at least 2%. Men have one-tenth this prevalence.

LEARNINGS

What is Hashimoto's thyroiditis?
Thyroiditis is the inflammation of the thyroid gland. Hashimoto's thyroiditis is the most common form of thyroiditis. Classified as an autoimmune disorder, Hashimoto's thyroiditis causes an autoimmune reaction, with antibodies attacking the thyroid gland. The cause of Hashimoto thyroiditis is unknown.

What are the symptoms of Hashimoto's thyroiditis?
The following are the most common symptoms. However, each individual may experience symptoms differently:

The symptoms of Hashimoto's thyroiditis may resemble other conditions or medical problems. Consult a physician for diagnosis.

How is Hashimoto thyroiditis diagnosed?
In addition to a complete medical history and medical examination, diagnostic procedures for Hashimoto thyroiditis may include blood tests to detect levels of thyroid hormone and thyroid antibodies.

Treatment for Hashimoto's thyroiditis:
Specific treatment for Hashimoto's thyroiditis will be determined by your physician based on:

Specific treatment is currently not available for Hashimoto's thyroiditis. Hashimoto's thyroiditis usually results in hypothyroidism (an underactive thyroid gland), which can be treated with hormone replacement therapy (the administration of thyroid hormone). Hormone replacement therapy usually alleviates the goiter condition. However, if goiter does not improve, surgery may be required.

http://www.umm.edu/endocrin/hashim.htm

Hashimoto's Thyroiditis is a type of autoimmune thyroid disease in which the immune system attacks and destroys the thyroid gland. The thyroid helps set the rate of metabolism, which is the rate at which the body uses energy. Hashimoto’s stops the gland from making enough thyroid hormones for the body to work the way it should. It is the most common thyroid disease in the U.S.

An autoimmune disease occurs when the body's immune system becomes misdirected and attacks the organs, cells or tissues that it was designed to protect. About 75% of autoimmune diseases occur in women, most often during their childbearing years.

Some patients with Hashimoto's Thyroiditis may have no symptoms. However, the common symptoms are fatigue, depression, sensitivity to cold, weight gain, forgetfulness, muscle weakness, puffy face, dry skin and hair, constipation, muscle cramps, and increased menstrual flow. Some patients have major swelling of the thyroid gland in the front of the neck, called goiter.

There is some evidence that Hashimoto’s Thyroiditis can have a hereditary link. If autoimmune diseases in general run in your family, you are at a higher risk of developing one yourself.

Your doctor will perform a simple blood test that will be able to tell if your body has the right amount of thyroid hormones. This test measures the TSH (thyroid stimulating hormone) to find out if the levels are in the normal range. The range is set by your doctor and should be discussed with you. Work with your doctor to figure out what level is right for you. There are other available tests that your doctor may choose to do if need be, such as a blood test to measure the level of "active thyroid hormone" or Free T4 and a scan (picture) to look at the thyroid.

Hypothyroidism caused by Hashimoto's Thyroiditis is treated with thyroid hormone replacement. A small pill taken once a day should be able to keep the thyroid hormone levels normal. This medicine will, in most cases, need to be taken for the rest of the patient's life. When trying to figure out the amount of hormone you need, you may have to return to your doctor several times for blood tests to guide adjustments in the medicine dose. It is important that the dose be right for you. A yearly visit to your doctor will help keep your levels normal and help you stay healthy overall. Be aware of the symptoms. If you note any changes or the return of symptoms, return to your doctor to see if you need to have your medicine dosage adjusted.

If left untreated, hyporthyroidism can cause further problems, including changes in menstrual cycles, prevention of ovulation, and an increased risk of miscarriage. Symptoms such as fatigue, depression and constipation, may progress and there can be other serious consequences, including heart failure. It is also important to know that too much thyroid replacement hormone can mimic the symptoms of hyperthyroidism. This is a condition that happens when there is too much thyroid hormone. These symptoms include insomnia, irritability, weight loss without dieting, heat sensitivity, increased perspiration, thinning of your skin, fine or brittle hair, muscular weakness, eye changes, lighter menstrual flow, rapid heart beat and shaky hands.

It is important to get checked out by your doctor more often if you are pregnant. Inadequately treated thyroid problems can affect a growing baby, and the thyroid replacement needs of pregnant women often change. A doctor can help you figure out your changing medicine needs.

http://www.4woman.gov/faq/hashimoto.htm

__________________________________________________________________________________

__________________________________________________________________________________

Hashimoto's Thyroiditis. Hashimoto's Thyroiditis (also called autoimmune or chronic lymphocytic thyroiditis) is the most common type of thyroiditis. It is named after the Japanese physician, Hakaru Hashimoto, that first described it in 1912. The thyroid gland is always enlarged, although only one side may be enlarged enough to feel. During the course of this disease, the cells of the thyroid becomes inefficient in converting iodine into thyroid hormone and "compensates" by enlarging (for a review of this process see our function page). The radioactive iodine uptake may be paradoxically high while the patient is hypothyroid because the gland retains the ability to take-up or "trap" iodine even after it has lost its ability to produce thyroid hormone. As the disease progresses, the TSH increases since the pituitary is trying to induce the thyroid to make more hormone, the T4 falls since the thyroid can't make it, and the patient becomes hypothyroid. The sequence of events can occur over a relatively short span of a few weeks or may take several years.

Treatment is to start thyroid hormone replacement. This prevents or corrects the hypothyroidism and it also generally keeps the gland from getting larger.

In most cases the thyroid gland will decrease in size once thyroid hormone replacement is started.

Thyroid antibodies are present in 95% of patients with Hashimoto's Thyroiditis and serve as a useful "marker" in identifying the disease without thyroid biopsy or surgery.

Thyroid antibodies may remain for years after the disease has been adequately treated and the patient is on thyroid hormone replacement.

http://www.endocrineweb.com/thyroiditis.html

______________________________________________________________________________

Hashimoto's Thyroiditis is an autoimmune thyroid disease that affects approximately 5 percent of the adult population, and is seen increasingly in women as they grow older. In a patient with Hashimoto's Thyroiditis, autoantibodies and the cytotoxic cell mediated immune response work to attack and destroy the patient's own thyroid tissue. This damage to the thyroid gland results in hypothyroidism, or thyroid underactivity. Hashimoto's patients may experience tiredness, forgetfulness, depression, coarse dry skin, slow heartbeat, weight gain, goiter, intolerance to cold or constipation. These symptoms describe a metabolism slowdown, driven by a loss in thyroid hormone production. Hashimoto's Thyroiditis may begin as mild thyrotoxicosis, but can progress to overt hypothyroidism and myxedema.

A Hashimoto's Thyroiditis patient would present the elevated TSH values and possibly low thyroid hormone levels characteristic of hypothyroidism. However, a high concentration of thyroid autoantibodies (TPOAb in particular) is the distinguishing evidence for a diagnosis of Hashimoto's Thyroiditis. Greater than 90 percent of all Hashimoto's Thyroiditis patients are positive for TPOAb. A Radioactive Iodine Uptake Test (RAIU) would also demonstrate a low uptake rate.

Treatment for Hashimoto's Thyroiditis will include thyroid hormone replacement therapy and regular monitoring by a physician to insure proper hormone levels are maintained.

http://thyroid.about.com/blcohen.htm

______________________________________________________________________________

Hashimoto's Thyroiditis Hashimoto's Thyroiditis is an auto-immune inflammation of the thyroid gland. This means that the body can sometimes aim an immune attack, similar to the way it might fight germs or cancer, against its own thyroid gland. When that occurs, white blood cells called lymphocytes can infiltrate into the tissue of the thyroid gland. When doctors remove small amounts of thyroid tissue, either with a needle biopsy or during surgery, pathologists are able to see this infiltration, using microscopes. Blood tests can also demonstrate antibodies against the thyroid gland. Hashimoto's is more common in women, especially of child-bearing age. It can result in diffuse swelling of the thyroid gland. Patients may not have any thyroid function complaints at all. Sometimes patients can develop symptoms of low thyroid function, and rarely, overactive thyroid symptoms. If patients do develop low thyroid complaints it is recommended that they receive thyroid hormone replacement. However, some patients with Hashimoto's Thyroiditis develop classic symptoms of low thyroid function and still have normal thyroid blood tests. They are often told that since their thyroid tests are normal, they can't benefit from thyroid treatment. In Dr. Wilson's experience, patients with Hashimoto's thyroiditis and Wilson's Temperature Syndrome respond indistinguishably from other patients suffering from WTS. The Hashimoto's patients are no more, or less likely to respond favorably to the treatment, have side effects, or to relapse once their symptoms have been corrected. In addition, doctors report that they've seen anti-thryoid antibody levels drop in Hashimoto's patients treated with T3. In other words patients with Hashimoto's disease may have normal blood tests, low body temperatures, and classic symptoms of low thyroid function. They may be told that they're symptoms aren't due to low thyroid function. Yet, their symptoms may respond dramatically well to proper T3 therapy for Wilson's Temperature Syndrome, and remain improved even after the treatment's been discontinued, thus providing a persistent cure for their complaints.

_______________________________________________________________________

Hashimoto's Thyroiditis

Hashimoto’s disease is a member of the family of “auto-immune” diseases such as Rheumatoid arthritis.  These diseases are characterized by an immune system that, for some reason, identifies the patient’s own tissue as being “foreign” or not a normal, natural part of that person’s body.  A good example of this is demonstrated when a patient receives a kidney transplant and the immune system recognizes that this new tissue is, indeed, foreign.  The immune system then makes antibodies to go and attack this “foreign” tissue.  This results in a battle between the antibodies and the tissue perceived as foreign, and this results in inflammation.  In the case of the kidney, it causes a “nephritis”.  In the case of the rheumatoid arthritis patient, the joint capsule is attacked, and this causes an “arthritis”.  In the thyroid it causes a “thyroiditis”.

There are other ways the thyroid gland can become inflamed and a thyroiditis results, but if the inflammation is due to the patient producing antibodies against his or her own thyroid gland, then it is called Hashimoto’s auto-immune chronic lymphocytic thyroiditis…..a big name we simply refer to as Hashimoto’s Disease, and for this discussion we will simply say “chronic thyroiditis”. 

Chronic thyroiditis takes on importance in several ways.  First, years of inflammation can lead to destruction of normal thyroid tissue, which in time can result in low thyroid hormone levels in the blood, or a disorder known as “hypothyroidism”.  This will require treatment with lifelong thyroid medication to insure that the patient always has normal levels of thyroid hormone in the blood stream.

Second, extended periods of inflammation can lead to scarring and fibrosis and sometimes the formation of a round, hard nodule that is very difficult to distinguish from a thyroid tumor or even a thyroid cancer.  These patients will sometimes have to undergo a thyroidectomy for this reason. 

Third, all scar tissue wants to get smaller.  This is called the process of “contracture”.  For example, if you get a 6-inch cut on your leg today, a scar will form.  If you measure that scar next year, lets say, it may only be 5 ½ inches long.  Well, scar tissue in the thyroid gland also wants to get smaller, but the thyroid gland sort of wraps around the windpipe and the esophagus to some degree.  When this scar tissue undergoes contracture it can put pressure on those structures and produce what are called “compression symptoms”, that is, difficulty in breathing or swallowing.  Some patients have actually choked on their food and have required the Heimlich maneuver because of the tightness that has been created.  Others say that they have difficulty in breathing, especially when they lie down.  These patients may require thyroidectomy for relief of these symptoms. 

Fourth, about 30% of our patients with thyroid cancer are also found to have chronic thyroiditis.  This does not mean that if you have chronic thyroiditis that you will be certain to get thyroid cancer, but note is made of this casual relationship.  There are a few voices out there that would recommend that all patients with Hashimoto’s Disease undergo thyroidectomy.  This seems a bit radical and a very large number of patients would undergo unnecessary thyroid surgery.  Close and thoughtful observation by a thyroid specialist seems to be a prudent course of action for patients with chronic thyroiditis.  Surgery can always be recommended if a patient develops a mass or symptoms which require further treatment, with little negative impact on prognosis.  Please remember, I am discussing this topic in general terms for informational use only.  There is no substitute for you and your physician making medical decisions based on your individual and specific case.

Fifth, some patients with chronic thyroiditis may suffer intermittent bouts of hyperthyroidism, as the disease is known to have flare-ups with release of excess quantities of thyroid hormone now and again.  These flare-ups require medical treatment.  Only rarely is surgery required because of failure of this medical treatment.

Sixth, there are rare instances of lymphoma developing within the thyroid gland.  Lymphoma is a cancer of the lymphatic system and can manifest itself in many ways, one way being enlargement of lymphatic tissue or lymph nodes.  In the thyroid gland, this is usually a rapidly growing mass and it is important to distinguish this from a possible anaplastic cancer of the thyroid, which is extremely lethal.  Often these lymphoma patients have long-standing chronic lymphocytic thyroiditis, and the lymphoma is believed by some, to arise in this background of chronic inflammation and irregular cells.

The diagnosis of Hashimoto’s Disease is really quite straightforward.  First, an experienced examiner can almost always suspect Hashimoto’s Disease based on physical examination alone.  The gland is usually slightly enlarged, often tender to the touch, and the upper and lower parts of the thyroid lobes are usually somewhat blunted or thickened.  Next, there is a blood test called the thyroid antiperoxidase antibody test that is used to detect the presence of the autoimmune antibodies.  This is almost 100% accurate, but I have had a few patients I have treated for Hashimoto’s thyroiditis in spite of the fact that they had a negative antibody test.  These people had classic symptoms and physical findings of the disease.

And this brings us to treatment.  Surgery is not the treatment for Hashimoto’s thyroiditis alone, but it is used to treat some of the effects of the disease as described above.  Probably the most appropriate treatment for chronic thyroiditis is the use of thyroid hormone medication.  By taking the correct amount of thyroid hormone by mouth, the thyroid gland will soon stop functioning, as it will have no need to continue its work.  The only reason the thyroid gland functions at all is because the pituitary gland in the brain sends down a hormone that stimulates the thyroid gland to work.  By taking thyroid medication by mouth, we are actually “tricking” the pituitary gland into believing that the thyroid is functioning normally, and it therefore stops sending this messenger down to stimulate the thyroid gland to work.  Once the thyroid stops working, it will sort of fall off the radar screen of the immune system and it will no longer send antibodies to attack the thyroid gland.  If the gland is not attacked, there is no inflammation…no inflammation, no destruction of the normal thyroid tissue…therefore there will not be formation of scar tissue, and so on.  This treatment then assures that the body will maintain normal thyroid hormone levels in the blood stream from the medication, and hopefully all of the bad effects of chronic thyroiditis can be avoided, such as hypothyroidism, tenderness, formation of thyroid masses, compression symptoms, and so on.  It is important to note, however, that the earlier treatment begins, the more successful it is.  Often I see patients after years of chronic inflammation and scarring and none of that can be undone or reversed by medical treatment. 

If you have Hashimoto’s Disease, sit down with your doctor and discuss it with him or her.  Choose the treatment plan that is best for you and your individual needs.

http://www.thyroidcancer.com/hashimotos_thyroiditis.htm

____________________________________________________________________________

Brand name	Generic Name
Synthroid	Levothyroxine ( T4)
Levoxyl	Levothyroxine ( T4)
Throlar	Levothyroxine ( T4) + Triiodothyronine ( T3)  Source : Synthetic
Armour Thyroid	Levothyroxine ( T4) + Triiodothyronine ( T3) Source : From Pig
Cytomel	Triiodothyronine ( T3)

http://www.onlinemedinfo.com/Thyroid.htm

____________________________________________________________________________

Ranitidine may cause other side effects. Call your doctor if you have any unusual problems while taking this medication.

6. CIPROFLOXACIN (100 g)                                                                Classification: Antibiotic

            Ciprofloxacin is an antibiotic used to treat certain infections caused by bacteria. Ciprofloxacin tablets and suspension (liquid) are used to treat pneumonia (lung infection); bronchitis (infection of the tubes that lead to the lungs); some types of gonorrhea (a sexually transmitted disease); diarrhea caused by bacteria; typhoid fever (a contagious illness common in developing countries); and bone, joint, skin, prostate (a male reproductive gland), sinus, and urinary tract (bladder) infections. Ciprofloxacin is also used to prevent and/or treat anthrax in people exposed to anthrax germs in the air. Ciprofloxacin is also used with another medication to treat certain infections of the internal organs. Ciprofloxacin extended release (long-acting) tablets are used to treat urinary tract and kidney infections. Ciprofloxacin is in a class of antibiotics called fluoroquinolones. It works by killing bacteria. Antibiotics will not work for colds, flu, or other viral infections.

7. SALBUTAMOL/ ALBUTEROL                                                Classification: Antihistamine

Generic Name: albuterol (al BYOO teh rall)
Brand Names: Proventil, Proventil Repetabs, Ventolin, Volmax

            Albuterol is used to prevent and treat wheezing, shortness of breath, and troubled breathing caused by asthma, chronic bronchitis, emphysema, and other lung diseases. Albuterol inhalation also is used to prevent breathing difficulties (bronchospasm) during exercise. Albuterol is in a class of medications called beta-agonists. It works by relaxing and opening air passages in the lungs, making it easier to breathe.

SOAPIE

Patient’s Name:         Hortelano, Manny                          Ward 5, Male Surgical Ward,  Bed 25

Date: January 12, 2006                                  Time: 10:00 A.M.                                     Diet: NPO

S>”Day, nabalaka gyud ko pag-ayo kay pagkadako sa tahi sa akong tiyan,” as verbalized.

O>received pt. lying on bed, sleeping č ongoing #10 D₅NM 1L@30gtts/min, infusing well @ ® forearm; č remaining 200 mL.

   >č FBC attached to urobag

   >abrasions on ® mandibular, patellar and thoracic areas

   >several scars on left forearm noted

   >č NGT-to-drain, light, watery secretions noted

   >14 cms. Suture on abdomen

   >surgical incision on ® abdomen noted

   >grimace of face noted upon movement

   >with the ff V/S: T-37.2ºC ; P-65 bpm ; R- 21 cpm ; BP-140/100 mmHg

A>Impaired Skin Integrity R/T Break or disruption in the continuity of the skin surface 2º to Exploratory Laparotomy

P>After 2 hours of nursing intervention, client will verbalize understanding and ability to manage situation.

I>encourage pt. to intake fruits and vegetables to assist body’s natural process of repair

 >rendered health teachings and discussed techniques for a faster healing process

 > fixed dressings and wound coverings, drainage appliances

 >removed wet and wrinkled linens

 >rendered sponge bath and oral care č Bactidol

 >elevated bed to High Fowler’s position

 >applied padding devices to bony prominents (putting of pillows)

 >monitored I&O

E>Patient was receptive and cooperative to health teachings, and was able to understand his situation.

GLECIL ANN B. PAULO           /      KENDRICK DILLA CAÑARES, RN

CNU-CN      CLASS 2008        /                       Clinical Instructor

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a695011.html

http://72.14.203.104/search?q=cache:vOYzk31sSPIJ:www.edu.rcsed.ac.uk/pps/pps83.pps+what+is+acute+abdomen&hl=en

http://www.avonvets.co.uk/1styr_hands/Acute_Abdo.html

http://www.nlm.nih.gov/medlineplus/druginfo/uspdi/202318.html]

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682399.html

http://www.nlm.nih.gov/medlineplus/druginfo/medmaster/a682871.html

http://www.drugs.com/mtm/ciprofloxacin.html

http://www.drugs.com/mtm/albuterol.html