KB is a 65-year-old man admitted to the hospital after a 5-day episode of "the flu" with symptoms of dyspnea on exertion, palpitations, chest pain, insomnia, and fatigue. KB was diagnosed with Graves' disease 6 months ago and placed on methimazole (Tapazole) 15 mg/day. His other past medical history includes heart failure and hypertension requiring antihypertensive medications; however, he says that he has not been taking these medications on a regular basis. Vital signs (VS) are 150/90, 124 irregular, 20, 100.2°F (37.9°C). Admission assessment findings are height 5 ft 8 in (173 cm), weight 132 lb (60 kg), appears anxious and restless, loud heart sounds, bounding radial pulses, 1+ pitting edema noted in bilateral lower extremities, diminished breath sounds with fine crackles in the posterior bases, and hyperactive bowel sounds. KB begins to cry when he tells you he recently lost his wife. You notice someone has punched several more holes in his belt so he could tighten it.

Which of KB's assessment findings represent manifestations of hypermetabolism related to the effect of excess circulating thyroid hormone? Select all that apply.

1. Ensure MDHCP has discussed risks and benefits of blood transfusion. (a)
2. Educate patient on signs and symptoms of transfusion reaction. (d)
3. Obtain cross match and send it to blood bank. (b)
4. Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs. (e)
5. Initiate transfusion through a large gauge IV per hospital protocol. (c)
6. Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes. (f)
7. Increase rate of transfusion and monitor patient frequently. (g)
8. Ensure transfusion is complete within 4 hours of starting. (h)
9. Continue to monitor patient for transfusion reaction for 24 hours following transfusion. (i)

Rationale:

1. Ensure MDHCP has discussed risks and benefits of blood transfusion: It's essential that the healthcare provider discusses with the patient the potential risks and benefits of receiving a blood transfusion. This step is crucial for informed consent.
2. Educate patient on signs and symptoms of transfusion reaction: Before starting the transfusion, the patient should be educated on what signs and symptoms to watch out for that might indicate an adverse reaction, such as fever, chills, hives, or shortness of breath.
3. Obtain cross match and send it to blood bank: A blood sample is taken from the patient to determine their blood type and to perform a crossmatch, which ensures that the donor blood is compatible with the patient's blood.
4. Gain blood from bank, confirm correct patient, correct product, correct cross match with 2 RNs: Once the blood is ready, two registered nurses (RNs) will verify the patient's identity, the blood product, and the crossmatch results to ensure everything is correct before proceeding.
5. Initiate transfusion through a large gauge IV per hospital protocol: The blood transfusion is started using a large gauge intravenous (IV) line, as per hospital protocols to ensure proper flow and reduce complications.
6. Start transfusion slowly for the first 15 minutes and stay with patient for the first 15 minutes: The transfusion is started at a slow rate to monitor for any immediate adverse reactions. The healthcare provider stays with the patient during this time to closely observe them.
7. Increase rate of transfusion and monitor patient frequently: If no adverse reactions are noted in the first 15 minutes, the rate of transfusion can be increased. The patient is monitored frequently throughout the transfusion for any signs of a reaction.
8. Ensure transfusion is complete within 4 hours of starting: Blood products should be transfused within 4 hours to minimize the risk of bacterial growth and to ensure the effectiveness of the transfusion.
9. Continue to monitor patient for transfusion reaction for 24 hours following transfusion: After the transfusion is complete, the patient is monitored for at least 24 hours for any delayed transfusion reactions, such as fever, allergic reactions, or other complications.

Choice A reason: Addison's Disease is characterized by insufficient production of adrenal hormones, leading to symptoms like weight loss, hyperpigmentation, low blood pressure, and severe fatigue. The lab findings would typically show low sodium, high potassium, and low cortisol levels. RM's lab results and symptoms are not consistent with Addison's Disease, making this an unlikely diagnosis.
Choice B reason: Cushing syndrome results from excess cortisol production, often causing weight gain, particularly around the abdomen and face, thinning skin, and hypertension. RM's symptoms of fatigue, dry skin, hair loss, and weight gain without dietary changes do not align with Cushing syndrome, and her lab results do not indicate elevated cortisol levels.
Choice C reason: Hyperthyroidism is characterized by excessive thyroid hormone production, leading to symptoms like weight loss, anxiety, palpitations, and heat intolerance. RM's symptoms of weight gain, fatigue, and cold intolerance, along with her lab results showing low T4 and T3 and elevated TSH, are not consistent with hyperthyroidism.
Choice D reason: Hypothyroidism occurs due to an underactive thyroid gland producing insufficient thyroid hormones. This leads to symptoms such as fatigue, weight gain, cold intolerance, dry skin, hair loss, and constipation. RM's lab results showing low T4 and T3 levels and elevated TSH align with the diagnosis of hypothyroidism. The body's response to low thyroid hormone levels is to increase TSH production in an attempt to stimulate the thyroid gland. The clinical presentation and lab findings point towards hypothyroidism as the correct diagnosis.