Signature Assignment – Current EBP – Acute Health Problem

Please follow the rubric and also add conclusion as in the sample.

Assignment Prompt

Select a client from clinical experience with an acute health problem or complaint requiring at least two visits. Submit a complete history and physical H & P from the initial visit with this client and a focused SOAP note for the follow-up visit. Based on this client’s condition, conduct a literature search for two research articles that discuss various approaches to the treatment of this condition. Peer reviewed articles must address the standardized procedure or guidelines for this diagnosis. Incorporate the research findings into the decision-making for this client’s treatment. In the paper, compare and contrast or address how treatment or the plan may have been different based on the research findings. The discussion on relating research to practice should be 3-4 pages and the total paper should be no longer than 8 pages including references. The research articles must be an original research contributions (no review articles or meta-analysis) and must have been published within the last five years. Cover the criteria listed below. The paper should be APA formatted and no longer than 8 pages.

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· Reviews topic and explains rationale for its selection in the context of client care. (2 pts)

· Evaluates key concepts related to the topic. 2 pts)

· Describes multiple viewpoints if this is a controversial issue or one for which there are no clear guidelines. (2 pts)

· Assesses the merit of evidence found on this topic i.e. soundness of research (5pts)

· Evaluates current EBM guidelines, if available. Or, recommends what these guidelines should be based on available research. Discuss the Standardized Procedure for this diagnosis. (5 pts)

· Discusses how the evidence did impact/would impact practice. What should be done differently based on the knowledge gained? (3 pts)

· Consider cultural, spiritual, and socioeconomic issues as applicable. (2pts).

· Utilizes APA guidelines, cite references (2 pts)

· Writing style at the graduate level (2pts)

Expectations

· Length: no longer than 8 pages, including references

· Format: APA Formatted

· Research: citations required

See USU NUR Research Paper Rubric for additional details and point weighting.

HYPOGONADISM 1

Clinical evaluation and management of hypogonadism

United States University

FNP: 593 Acute illnesses across the lifespan

Brittany Chavez

12/10/2021

TITLE OF PAPER

Clinical evaluation and management of hypogonadism

The purpose of this paper is to discuss Hypogonadism in regard to clinical evaluation,

symptomatic presentation, management and evaluation of clinical guidelines. The paper will

explore differing viewpoints and key concepts in relation to hypogonadism. The effects of

cultural, spiritual and beliefs in treatment and evaluation, and the impact of research on this

endocrine imbalance. Also reviewed will be research studies addressing the clinical symptoms

and trials for new treatment options.

Review of topic and rationale for selection of topic

Hypogonadism is a common endocrine disorder originating from two causes. Primary

hypogonadism is caused from a direct androgen imbalance originating from the testes. This

clinical syndrome which the testes fail to produce physiologic levels of testosterone and a normal

number of spermatozoa due to defects in the hypothalamic-pituitary-gonadal axis at one or more

levels. (Ross & Bhasin, 2016). This topic was chosen due to the frequency of cases seen in the

family practice setting. Hypogonadism is a common disorder associated with low bone density,

poor muscle mass, anemia, and sexual dysfunction that affects men in a variety of ways. Among

secondary osteoporosis risk factors, male hypogonadism is one of the most important, accounting

for progressive bone loss in aging men, especially when late-onset hypogonadism is

diagnosed (LOH). (Rochira, 2020) This disorder can affect all aspects of life and greatly impact

the emotional state and feelings of self-worth. This paper will address primary hypogonadism in

terms of diagnostic, and treatment based on guidelines.

Evaluation of key concepts related to the topic

The key concepts evaluated for the paper includes disease process in formation of

androgen deficiency. Androgens are important for male reproductive and sexual functions, body

TITLE OF PAPER 3

composition, erythropoiesis, muscle and bone health, and cognitive functions. Symptoms

presentation commonly seen in the primary care setting. Diagnostic criteria in the evaluation to

determine the extent of deficiency in relation to the symptoms presented and the treatment

guidelines based on efficacy and positive outcomes.

Primary Hypogonadism (PHG) is often underdiagnosed in the clinical setting due to the

ambiguous symptoms presented often mimicking depression or often overlooked as normal

aging process. These symptoms may present with decreased libido, weight gain, fatigue, low

stamina, decrease in muscle mass, decreased energy, sleep disturbances, mood fluctuations and

irritability.

It is essential for the provider to consider hormonal deficiency into the differential

diagnosis to effectively diagnose and rule out PHG. Diagnosis of PGH include total serum

testosterone taken in a time sensitive manner as the peak testosterone in men is roughly 8am.

Diagnosis requires at minimum 2 low testosterone levels in different occasions. Deficiency is

noted to be below 300 testosterone. FSH and LH are required to be tested in addition to

testosterone as well as ruling out other factors such as endocrine, thalamus, pituitary, and thyroid

as a cause for the decrease in testosterone. Age is a consideration in the diagnosis of PHG as

there are multiple types of hypogonadism that should be considered for a younger patient such as

congenital hypogonadism. In the patient case presented in appendix B the patient was found to

have serum testosterone of 250. The treatment however was to be delayed until further testing

was completed to follow diagnostic guidelines.

Treatment of PHG has been debated as there are pro’s and cons of this therapy. Recent

studies have indicated that testosterone replacement therapy (TRT) can greatly improve the

patients quality of life as well as can be cardioprotective. Testosterone administration was found

TITLE OF PAPER 4

to increase skeletal muscle mass and performance while also increasing myogenic gene

programming, myocellular translational efficiency and capacity, resulting in higher protein

turnover and net protein accretion. (Gharahdaghi et al., 2019). Some studies have found that TRT

could potentially be harmful in the older population, however there is lack of supporting

evidence for this case.

Description of multiple viewpoints

Androgens are important for male reproductive and sexual functions, body composition,

erythropoiesis, muscle and bone health, and cognitive functions. (Professionals, 2021).

Guidelines for treatment of this disorder differ in the aspect of age. Multiple studies were found

to state there despite lack of full study to the matter there is thought to be a potential

cardiovascular risk associated with TRT in patients who are older. On the other hand there is also

data and research studies finding that TRT can reduce LDLs total cholesterol, increase skeletal

muscle mass and improve gene function. The risk associated with not treating this condition

could lead to depression, impaired relations, increase in cholesterol, increased weight gain, and

osteoporosis.

Assessment of the merit of evidence found on this topic (soundness of research)

The research in the 2 studies reviewed were sound in their method based on the method,

large sample size, randomization, time frame of research study conducted, and the findings of the

results closely aligned with the current guidelines in terms of diagnosis and treatment.

Evaluation of current EBM guidelines

Guidelines indicate that treatment with TRT should be started and have been shown to

improve the overall health and outcome of patients. The one consideration of withholding

treatment includes obesity as there is greater risk of adverse outcomes. These patients should first

TITLE OF PAPER 5

be initiated on a lifestyle/weight reduction plan prior to starting to decrease comorbidities that

may place them at greater risk. Although the effects of testosterone treatment are usually minor,

they can have a positive impact on body composition, metabolic control, psychological, and

sexual parameters. Observational studies reveal a link between restored physiological

testosterone levels, muscle mass, and strength, as measured by leg press strength and quadriceps

muscle volume. (Professionals, 2021)

Cultural, spiritual, and socioeconomic considerations

Considerations to spiritual and cultural beliefs should be included in practice when

considering treatment with hormone therapy. Certain religious beliefs forbid any form of animal

or human product be put in the body. For these patients it is important to explore natural options

to improve the bodies ability to manufacture the testosterone on its own and any type of hormone

replacement is contraindicated for these groups and they are considered unclean.

Discussion regarding the Standardized Procedure for this diagnosis

Standardized treatment for primary hypogonadism should include lipid panels, cardiac

evaluation and EKG prior to initiating treatment due to the variability and lack of evidence for

the true effect on cardiac function in the geriatric population. The treatment measures would

remain the same due to the risk of osteoporosis and significant mental health and changes in the

relationship that can occur along with the patients physical symptoms.

Discussion on how the evidence did impact/would impact practice

The outcomes of increase virility, improved mood, improved stamina and decrease in

lipids outweight the risk of a possible cardiac challenge that has yet to be proven. I would want

to conduct more specific testing on the affects of testosterone replacement in the older

population. After reviewing in depth this topic and guidelines I would be more aware of the risk

TITLE OF PAPER 6

factor of hypogonadism and be more willing to approach the topic before simply assuming

depression based on the patients changes in mood and fatigue.

Conclusion

In conclusion, primary hypogonadism is a common occurrence in primary care and often

underdiagnosed. This condition affects all age groups and can cause significant health concerns

that affect the patients overall health both physical and mental. Understanding the reasoning

behind the condition and having the insight to consider this in the differential diagnosis is an

important factor to consider when addressing patient care. Patients may present with ambiguous

symptoms that often mimic depression. Treatment should be initiated baring significant risk

factors such as morbid obesity, cardiac failure or renal impairment. The guidelines are

comprehensive and recommend the treatment with TRT to improve quality of life and positive

outcomes.

TITLE OF PAPER 7

References

Gharahdaghi, N., Rudrappa, S., Brook, M. S., Idris, I., Crossland, H., Hamrock, C., Abdul Aziz, M. H., Kadi, F., Tarum, J., Greenhaff, P. L., Constantin-Teodosiu, D., Cegielski, J., Phillips, B. E., Wilkinson, D. J., Szewczyk, N. J., Smith, K., & Atherton, P. J. (2019). Testosterone therapy induces molecular programming augmenting physiological adaptations to resistance exercise in older men. Journal of cachexia, sarcopenia and muscle, 10(6), 1276– 1294. https://doi.org/10.1002/jcsm.12472

Professionals, S.- O. (2021). EAU guidelines: Male hypogonadism. Uroweb. Retrieved December 16, 2021, from https://uroweb.org/guideline/male-hypogonadism/#5

Rochira, V. (2020). Late‐onset hypogonadism: Bone Health. Andrology, 8(6), 1539–1550. https://doi.org/10.1111/andr.12827

Ross, A., & Bhasin, S. (2016). Hypogonadism: Its Prevalence and Diagnosis. The Urologic

clinics of North America, 43(2), 163–176. https://doi.org/10.1016/j.ucl.2016.01.002

https://doi.org/10.1002/jcsm.12472

https://doi.org/10.1016/j.ucl.2016.01.002

TITLE OF PAPER 8

Appendix A

Soap comprehensive

Subjective:

Patient: SG Age: 65 DOB: 04/23/1956 Gender: Male

Ethnicity: Caucasian

“I don’t feel like I used to”

HPI

Mr. G was last seen in clinic 1 year ago for a wellness check. Today he is here because he has not

been feeling himself. He reports increased fatigue, low libido, weight gain and loss of muscle

mass. He feels this has been going on for a while now and he is concerned because it was never

an issue before. His wife has noticed a difference in his energy and stamina, he is no longer

interested in many activities he used to enjoy and he is more easily fatigued. He is healthy

overall and works out 3x weekly but has been struggling with this in the last couple months. He

reposts there has been no change in his diet or lifestyle.

PMI: I10 Essential hypertension E78.00 Pure cholesterol

PMP: Surgery on left knee for meniscus repair 1987

MEDICATIONS: -Lisinopril 10 mg tab PO once daily -Vitamin D3 1000IU gel capsules: 2 capsules PO once daily

ALLERGIES: NKDA, no environmental or food allergies

TITLE OF PAPER 9

IMMUNIZATIONS: -Quadravalent influenza 10/18/2021 -Moderna covid vaccine 3/25/2021, 04/28/2021, 12/08/2021

FAMILY HISTORY: Parents: deceased -Father: age 87, HTN, AMI -Mother: 89 breast cancer No siblings. 3 children: no health concerns

SOCIAL HISTORY Exposure to substance/tobacco/ Illicit or rec drugs: non-smoker, denies alcohol or drug use.

Occupation: Construction worker

Nutrition: Follows dash diet and exercises 3 x weekly.

Sleep: Having difficulty sleeping, feels tired throughout the day. He guesses he sleeps maybe 6 hours nightly.

Leisure activities/hobbies: Enjoys outdoor activities, hiking kayaking, camping. In the winter snow shoeing.

Stress: Has been having increased stress due to frustration in lack of energy and libido.

Safety: No weapons in the homes, smoke detectors present and functional, fire extinguisher in home.

ROS: Constitutional: Negative for appetite change, fever and unexpected weight change.

HENT: Denies congestion, dental/mouth issues, hearing loss, trouble swallowing, loss of smell or rhinorrhea

Eyes: Denies any discharge or visual disturbances

Cardiovascular: Denies chest pain, shortness of breath, palpations and leg swelling.

Pulmonary: Denies difficulty breathing, wheezing, cough, hemoptysis, or chest tightness

Gastrointestinal: Negative for abdominal distention, abdominal pain, or blood in stool

Genitourinary: Negative for decreased urine volume, difficulty urinating and pelvic pain.

Musculoskeletal: Negative for gait problems, pain in muscle or joints bilaterally.

Skin: denies skin changes or issues, no rash, color changes or excessive dryness

TITLE OF PAPER 10

Neurological: Denies weakness, headaches, difficulty with memory or dizziness

Allergic/Immunologic: no food or medication allergies and has never been diagnosed with seasonal allergies. Has not experienced frequent or long-term sickness.

Psychiatric/Behavioral: Denies behavior issues, Admits to sleep disturbance, increased stress and depression

Objective

Vitals BP: 145/89 HR: 68 RR: 16 Temp: 98.6 Height: 5’9 Weight: 177lbs BMI: 26.14 kg/m2

General: Is well-dressed and tidy, and well developed. He appears to be aware and active, and he does not appear to be in mental or physical discomfort. Able to maintain adequate eye contact throughout the interview and exam.

HEENT: Extraocular Movements: Right eye- normal extraocular motion, and no nystagmus. Left eye- normal extraocular motion and no nystagmus. Normal conjunctiva/sclera, PERRLA noted. Head symmetrical without deformities. lesions or masses. Hair evenly disbursed. Ear canals clear with no erythema, or moisture. TM intact bilaterally.

Lungs/Thorax- Bilateral breath sounds, in all lung fields are clear and equal. No difficulty breathing noted. Chest wall symmetrical without barreling of chest.

Cardiovascular- Heart sounds are WNL, strong pulses throughout, no swelling in left or right lower legs.

Neurological: Alert and oriented to person, place and time. Speech is normal, without delay, memory and thought process is intact. Cranial Nerves II, III, IV, VI intact, visual fields normal in all quadrants. No sensory deficits noted. No tremor or abnormal muscle tone. Rapid alternating movements normal, gait is steady and as expected.

Musculoskeletal – General: Normal range of motion Right Shoulder: No tenderness or crepitus, normal range of motion normal strength Left Shoulder: No tenderness or crepitus, normal range of motion normal strength Cervical back: Normal range of motion, no tenderness, swelling, edema, deformity, erythema or rigidity, normal range of motion. Normal sensation

Gastrointestinal: Bowel tones brisk and equal all quadrants. Abdomen is flat and soft to palpation with no notable masses, or herniations. No distention or guarding with palpation.

Lymphadenopathy: No cervical adenopathy

TITLE OF PAPER 11

Neuro: A/O x4, gait even and smooth, bilateral muscle strength with no weakness noted.

Psychiatric: Appropriate mood and affect, behaviors, speech and judgement as expected.

Skin: Free of lesions or masses, smooth, with dryness noted on upper arms.

Assessment:

Differential DX:

– Z00.01 encounter for adult examination with abnormal findings.

– E29.1 Hypogonadism

– G47.00 Insomnia Unspecified

– Z13.29 Screening for endocrine abnormalities

– E34.9 Screening for hormonal imbalance

Final diagnosis: Z00.01 encounter for adult examination with abnormal findings.

Plan:

Diagnostic:

– Laboratory blood draw for TSH, testosterone, lipid panel, CBC, and CMP

Treatment: None at this time

Education:

– Discussed nutrition/ diet and exercise

– Setting routine for sleeping, avoiding read, or watching TV or using phone in bed.

– Keep log over next week twice daily of blood pressure readings to bring to next visit.

Follow up: Follow up in 1 week for lab results and further testing if needed.

Goals:

TITLE OF PAPER 12

– Increase sleep from 6 to 8 hours nightly

– Address increased fatigue at next visit.

Appendix B

TITLE OF PAPER 13

Follow up SOAP

Subjective:

Patient: SG Age: 65 DOB: 04/23/1956 Gender: Male

Ethnicity: Caucasian

“Here to follow up on laboratory results”

HPI

Mr. G was last seen in clinic 1 week ago with complaints of fatigue, decreased stamina,

decreased libido, and insomnia. He is here today with his wife to review his resent labs to help

determine if her has an endocrine or hormonal imbalance causing his symptoms. He reports that

he continues to struggle with sleep and decreased libido. He was not able to work out this week

as he was not “feeling up to it”. He denies illness, fever, or malaise at this time.