| Course | NU654 AGACNP Acute Care Diagnosis and Management III |
|---|---|
| Unit | Unit 10 |
| Paper type | Multi-system case study |
| Length | About 1,090 words, 6 pages double-spaced |
| Format | APA 7 student paper |
| School | Purdue University Global |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NU654 Unit 10
A Heart Rate of 164, a Temperature of 39.8 and a Yellow Tinge: A Multi-System Case Study of Thyroid Storm in a 41-Year-Old Woman Who Stopped Her Methimazole
[Student Name]
Purdue University Global
NU654: AGACNP Acute Care Diagnosis and Management III
Unit 10 Multi-System Case Study
[Instructor Name]
[Date]
The patient is composite; values, doses, dates and times are bracketed.
Section 1: Arrival, [Day 0], [21:40]
Ms. [N.], a [41]-year-old office manager, was brought by her sister after [three] days of cough and fever, followed by [one] day of vomiting, diarrhea and confusion. She had Graves disease diagnosed [two] years earlier and stopped methimazole [three] months ago because she felt well. On arrival: temperature [39.8] C, atrial fibrillation at [164], blood pressure [138/58], respiratory rate [28], saturation [93] percent on room air. She was agitated and disoriented, with a fine tremor, a smooth goiter and bibasilar crackles. Her skin and sclerae were faintly yellow. First panel: TSH below [0.01] mIU/L, free T4 [7.2] ng/dL, total bilirubin [3.4] mg/dL, AST [96] and ALT [118] U/L, glucose [168] mg/dL, calcium [10.6] mg/dL, BNP [890] pg/mL, influenza A positive. The organ that drove the next decision: the heart. A ventricular rate of 164 with crackles meant heart failure was developing, and rate control could not wait for the diagnosis to be confirmed.
Section 2: Diagnosis, [Day 0], [22:30]
Thyroid storm is a clinical diagnosis. The Burch-Wartofsky point scale assigns points for temperature, central nervous system effects, gastrointestinal and hepatic dysfunction, heart rate, heart failure, atrial fibrillation and a precipitating event, and a total of 45 or more is highly suggestive of thyroid storm (Burch & Wartofsky, 1993). Ms. [N.] scored: temperature [25], delirium [20], jaundice [20], heart rate over 140 [25], moderate crackles [10], atrial fibrillation [10] and precipitant [10], for a total of [120].
The score confirmed what the bedside already showed: this was not uncomplicated hyperthyroidism with a fever, but a failure of several organs driven by thyroid hormone. A Japanese nationwide survey found mortality above 10 percent in thyroid storm, often from heart failure and multiple organ failure (Akamizu et al., 2012). She was moved to the intensive care unit. The organ that drove the next decision: the thyroid itself. Treatment had to stop the gland from making more hormone before anything else could last.
Section 3: Treatment Sequence, [Day 0], [22:45] to [Day 1], [02:00]
The ATA hyperthyroidism guideline describes a combined approach to thyroid storm: a beta-blocker, a thionamide, an inorganic iodine solution given after the thionamide, glucocorticoids and treatment of the precipitating event, with supportive care in an intensive care unit (Ross et al., 2016). For Ms. [N.], the order mattered:
1. [22:45] Methimazole [20 mg] every [six] hours through a nasogastric tube, chosen over propylthiouracil because her liver tests were already abnormal and propylthiouracil carries a risk of severe liver injury.
2. [22:50] Esmolol infusion, starting at [50] mcg/kg per minute, chosen over oral propranolol because its short action allowed quick reduction if her heart failure worsened.
3. [23:00] Hydrocortisone [100 mg] intravenously every [eight] hours.
4. [23:50] Potassium iodide solution, [five] drops every [six] hours, given at least one hour after the methimazole so the iodine would not become fuel for new hormone.
5. Cooling with acetaminophen and cooling blankets; aspirin avoided because it can displace thyroid hormone from its binding proteins.
6. Oseltamivir for influenza.
The organ that drove the next decision: the heart again, because the beta-blocker lowered her rate but also her pressure.
Choices Weighed in Section 3
Two choices deserve a longer explanation, because reasonable clinicians make them differently. The first is the thionamide. Propylthiouracil has a theoretical advantage in thyroid storm, since it also slows the peripheral activation of thyroxine into triiodothyronine, and many protocols prefer it for that reason. Its disadvantage is a rare but serious risk of liver failure. Ms. [N.] arrived jaundiced, and at that moment no one could say whether the jaundice came from the storm, from heart failure congesting her liver or from something else. Choosing a drug with its own liver risk would have made a rising bilirubin impossible to interpret. Methimazole at a high dose still stops new hormone production, and glucocorticoids add some of the conversion-blocking effect.
The second is the beta-blocker. Propranolol by mouth is the classic choice, but it lasts for hours. In a patient with crackles, a low diastolic pressure and a ventricle that later proved weak, a drug that could be switched off within minutes was safer. The cost was an infusion, a central line and closer monitoring, which the intensive care unit could provide.
Section 4: Complications, [Day 1]
By [04:00] her heart rate was [118], but her blood pressure had fallen to [92/54] and her crackles had increased. Bedside echocardiography showed a left ventricular ejection fraction of [35] percent with global hypokinesis, likely a thyrotoxic cardiomyopathy made worse by the rapid rate. Esmolol was reduced, furosemide given, and amiodarone was considered and rejected for rate control because its iodine content could worsen thyrotoxicosis later. By [12:00], her rate was [104] and her pressure [108/62]. Her bilirubin rose to [4.1] mg/dL on [Day 1], then fell on [Day 2] as her thyroid hormone level fell, which supported thyroid storm rather than a drug reaction as the cause. Her confusion cleared on [Day 2]. The organ that drove the next decision: the liver. With bilirubin falling, methimazole could continue safely, which kept definitive treatment options open.
Section 5: Handover and What Comes Next, [Day 5]
Ms. [N.] moved to the medical ward on [Day 4] in sinus rhythm, on oral propranolol, methimazole and a hydrocortisone taper. Iodide was stopped on [Day 5]. Her free T4 had fallen to [3.1] ng/dL. Endocrinology discussed definitive treatment, surgery or radioactive iodine after she is euthyroid, since a relapse after stopping medication had caused this storm. She chose surgery, to be scheduled in [six to eight] weeks. Before discharge she received careful teaching on why stopping methimazole on her own was dangerous, a written plan for missed doses and an appointment in [one] week. Her echocardiogram will be repeated at [three] months, since thyrotoxic cardiomyopathy often improves once hormone levels are controlled. Looking back across the five sections, the case turned on sequence more than on any single drug: rate first because the heart was failing, the gland next because nothing else would last, and the liver watched throughout because it decided which drug could safely stay on the chart until she was ready for surgery.
References
Akamizu, T., Satoh, T., Isozaki, O., Suzuki, A., Wakino, S., Iburi, T., Tsuboi, K., Monden, T., Kouki, T., Otani, H., Teramukai, S., Uehara, R., Nakamura, Y., Nagai, M., & Mori, M. (2012). Diagnostic criteria, clinical features, and incidence of thyroid storm based on nationwide surveys. Thyroid, 22(7), 661-679. https://doi.org/10.1089/thy.2011.0334
Burch, H. B., & Wartofsky, L. (1993). Life-threatening thyrotoxicosis: Thyroid storm. Endocrinology and Metabolism Clinics of North America, 22(2), 263-277. https://doi.org/10.1016/S0889-8529(18)30165-8
Ross, D. S., Burch, H. B., Cooper, D. S., Greenlee, M. C., Laurberg, P., Maia, A. L., Rivkees, S. A., Samuels, M., Sosa, J. A., Stan, M. N., & Walter, M. A. (2016). 2016 American Thyroid Association guidelines for diagnosis and management of hyperthyroidism and other causes of thyrotoxicosis. Thyroid, 26(10), 1343-1421. https://doi.org/10.1089/thy.2016.0229
Reading the NU 654 Unit 10 instructions
For Unit 10 you present a patient whose organ systems failed together, and you show how each decision was made across them. You follow the patient through time, explain the diagnosis with a validated tool, set out the treatment and its sequence, describe complications and their management, and end with the transition of care. Most prompts expect eight to nine pages. The case should read as one story rather than a list of organ problems, and each major decision should be supported by evidence and tied to the organ it protected. Definitive treatment and prevention of recurrence belong in the final section. Name the organ that drove each decision as you go. Keep the timeline dated throughout.
How the NU 654 Unit 10 example is put together
The example is organized in five dated sections. Section one gives the arrival findings and first panel. Section two scores the Burch-Wartofsky scale item by item and cites a nationwide survey on mortality, with a highlighted sentence. Section three lists the treatment steps in order with times, including why the iodine waits an hour after the thionamide. A section explains the choice of methimazole over propylthiouracil and esmolol over oral propranolol. Section four covers a thyrotoxic cardiomyopathy and a falling bilirubin. Section five describes handover, the choice of surgery and teaching, and closes with a sentence on sequence. Each section closes by naming the organ that set up the next one.
Reading the NU654 Unit 10 grading rubric
The Unit 10 rubric weighs clinical accuracy, the integration of systems, the justification of decisions, the handling of complications and the transition plan. Accuracy earns full points when findings and scores are correct and complete. Integration is weighted heavily and is judged on whether each section connects to the next through a clear decision. Decisions count when they are supported by guidelines and tied to the patient. Complications should be recognized and managed with reasons. The transition plan must address definitive treatment and prevention, since recurrence caused this admission. Explaining contested choices, such as which thionamide, usually earns additional credit for reasoning. A dated final section on prevention completes the case.
NU654 Unit 10 help: mistakes that cost points
The most common mistake is presenting each organ in its own section without showing how one drove the next decision. Another is giving iodine before the thionamide, which can supply the gland with material for new hormone. Students often choose a long-acting beta-blocker for a patient who may be in heart failure. Aspirin for fever is a frequent error in thyroid storm. Scores are sometimes given as a total without the items. And many case studies end at the ICU transfer without addressing definitive treatment or why the patient stopped her medication. Give every score with its items, and date every section so the sequence is clear.
Get an NU654 Unit 10 example written to your instructions
Final cases here range from sepsis with bleeding to a liver failure admission, a cardiac arrest survivor or a toxic ingestion. Supplied case or self-built outline, either can be sent with the rubric. Each section of the first case study, free within 24-48h, ends on the organ that drove the next decision. The paper above is an original model document written by our desk, not a submitted student paper and not an official Purdue University Global document.
More NU654 papers and MSN samples
- NU654 Unit 1: Stroke and Pulmonary Edema BP Post
- NU654 Unit 2: Deterioration Case, Guillain-Barre
- NU654 Unit 3: Competing Priorities, Aortic Stenosis
- NU654 Unit 4: Sepsis Management Paper, Dialysis
- NU654 Unit 5: Seminar Reflection, Adrenal Crisis
- NU654 Unit 6: Integrated Plan, Endocarditis
- NU654 Unit 7: Rapid Response Debrief, Opioid Toxicity
- NU654 Unit 8: Serious Illness Summary, ALS
- NU654 Unit 9: Overnight Plan, Subarachnoid Hemorrhage
- NU653 Unit 10: Learning Objectives Update
- NU652 Unit 10: Management Revision, Neutropenic Fever
- NU651 Unit 10: Pancreatitis Case Presentation
- NU650 Unit 10: Discharge Summary, Diverticular Bleed
NU654 Unit 10 questions, answered
Could the sample follow a different multi-system condition?
Yes. Acute liver failure, severe pancreatitis, a toxic ingestion or sepsis with disseminated clotting each involve several organs at once and fit the same structure. Name the condition and how much of the course the case should cover, and the sample tracks the organ driving each decision from the first abnormal finding to the final placement.
Where can I find a free NU654 Unit 10 sample paper?
The complete NU654 Unit 10 multi-system case study is on this page, with five dated sections, the Burch-Wartofsky score, the treatment sequence and the handover. For a different multi-system case, a free study can be written from your details.
What is the Burch-Wartofsky score in NU654 Unit 10?
A point scale for suspected thyroid storm that scores temperature, central nervous system effects, gastrointestinal and liver dysfunction, heart rate, heart failure, atrial fibrillation and a precipitating event. A total of 45 or more is highly suggestive; the sample's patient scored 120.
Why give iodine after methimazole in NU654 Unit 10?
Because iodine given first can be used by the overactive gland to make more hormone. Giving the thionamide at least an hour earlier blocks new hormone production, so the iodine then reduces hormone release instead.
What happens after thyroid storm in NU654 Unit 10?
Once the patient is stable and her thyroid levels are controlled, definitive treatment is discussed: surgery or radioactive iodine. The sample's patient chose surgery in six to eight weeks and received teaching on never stopping methimazole on her own.