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Start at slide 124
Terms in this set (50)
1. Results from a disorder of thyroid itself in terms of hormone secretion
2. Thyroid dysfunctions related to secretion of TSH or TRH
a. primary disorder
b. secondary disorder
1. Primary disorder
2. secondary disorders
what element is essential for the formation of thyroid hormone?
Iodide -> iodine
forms T3 and T4
Symptoms of Hyperthyroidism
What may be found on skin and eye exam of someone w hyperthyroidism?
-onycholysis, pretibial myxedema, warm and moist, hair thinning
nInflammation of extraocular muscles
nLid lag & stare
Bone issues in pt w hyperthyroidism?
osteoporosis and hypercalcemia
Heme findings in pt w hyperthyroidism
normochromic, normocytic anemia
Neuromuscular findings in hyperthyroidism?
nTremor (tongue and outstretched hands)
nBrisk DTR's, particularly relaxation phase
nProximal muscular weakness
What is it called when someone has hyperthyroidism but no sx:
pt with hyperthyroidism presents with the following sx after a stressful week at work:
"Thyroid Storm" (Thyrotoxic crisis)
Most common causes of thyrotoxicosis?
thyrotoxicosis= too much thyroid hormone, so
-Grave's disease MC
-Precipitated by: stress, infection, surgical emergency
-thyroiditis, hashimoto's, postpartum,
Autoimmune disease more common in women, with diffusely enlarged thyroid, *
*, and possible goiter, eye tearing/ proptosis/ paralysis/ loss of sight, and thyroid dermopathy
THYROID BRUIT IS PATHOGNOMONIC
How do Toxic solitary nodule & toxic multinodular goiter cause hyperthyroidism?
The nodules produce thyroid hormone, independent of regulation from TSH
what lab MUST BE TAKEN before ever testing a patient's thyroid function w radioactive iodine?
PREGNANCY TEST. radioactive iodine CId in pregnancy
This is a
nPostviral syndrome, very painful
nLow I-123 uptake, high ESR
nResolves few weeks to months
Subacute thyroiditis (dequervian's)
nSeen before autoimmune destruction & hypothyroidism
What is Hyperemesis gravidarum?
nTransient hyperthyroidism during pregnancy assoc with severe nausea &vomiting
nExcessive HCG stimulates TSH receptor
What is Postpartum Thyroiditis - Throtoxicosis From Painless Autoimmune Thyroiditis - Silent Thyroiditis?
how do you test for this?
-form of lymphocytic thyroiditis that occurs w/in 1 year after delivery.
-1/3 of patients get hyperthyroidism and then have a hypothyroid phase
can test with RAI uptake as long as the patient isn't nursing
What is the best screening test for hyperthyroidism?
TSH (will be low)
if TSH is low, then get a measure of T3 and T4
this test will be
nHigh in disorders with excess thyroid hormone production (Graves', TMNG)
nLow with leakage of thyroid hormone (thyroiditis)
I-123 scan & uptake
Treatment of hyperthyroidism
-Antithyroid drugs (PTU, Methimazole): Inhibit thyroid hormone synthesis
-Radioacltive iodine (I-131)
nUsually takes few weeks to months to be effective.
nOften causes permanent hypothyroidism
n? can worsen Graves' eye disease
-BBs for symptoms (atenolol/ propranolol)
side effects of antithyroid drugs like PTU and Methimazole?
1. Agranulocytosis (rare), but need CBC if fever or sore throat occur
A new Rx for Graves' ophthalmopathy is:
think: only mum could love those bulging eyes
What is the goal of treatment of hyperthyroidism during pregnancy?
a. keep mom's thyroid levels at the high-end of normal or slightly hyperthyroid range so the fetus has best chance of having normal thyroid function
b. -keep mom's thyroid levels at the low-end of normal or slightly hypothyroid range so the fetus has best chance of having normal thyroid function
c. Keep mom's thyroid function right in the middle
A. keep mom's thyroid levels at the high-end of normal or slightly hyperthyroid range so the fetus has best chance of having normal thyroid function
Treatment of Thyroid Storm
1. PTU 300 milligrams p.o. Q 6 hours or by NG tube or per rectum.
2. One hour after starting PTU, start SSKI 2 drops mixed in a cup of water bid.
3. Acetaminophen. Steroids. Maybe cooling blanket. Propranolol if no contraindications. Supportive measures.
Post -partum Treatment Hyperthyroidism?
-symptomatic treatment with beta blockers
Clinical Features of Hypothyroidism in Children?
-learning disabilities and short stature
Skin and eye findings in hypothyroidism?
-Dry and cool
-Nonpitting edema (think: foot edema in Italy when thyroid was low)
Facial findings in hypothyroidism?
(is this what I'm gonna look like in the future...?!)
neuromuscular findings in hypothyroidism?
nProximal muscle weakness
nMild elevation CK
Lab Abnormalities in Hypothyroidism
nDecreased free water clearance
nHigh chol (LDL and FFA)
nDecreased drug clearance
What condition occurs
nWhen severe hypothyroidism is complicated by trauma, infection, cold exposure, sedatives
nComatose, hypothermic, hypercapnic, hyponatremic
Causes of primary hypothyroidism?
-autoimmune: hashimoto's, polyglandular failure syndrome
-Congenital: thyroid agenesis, etc.
Causes of secondary hypothyroidism?
nPostpartum pituitary necrosis
Autoimmune disease causing hypothyroidism, esp in women. Thyroid feels enlarged and firm. Anti-thyroglobulin and antimicrosomal antibodies can be detected
Chronic Autoimmune Thyroiditis (Hashimoto's)
The most common kind of hypothyroidism in areas where iodine is not lacking.
Chronic Autoimmune Thyroiditis (Hashimoto's)
If you find elevated TSH levels in a patient, what must be measured directly next?
this pt has hypothyroidism
-Levothyroxine: Synthroid, Levoxyl, Levothroid
Treatment of Myxedema Coma
Give meds IV.
- L-thyroxine IV
- ventilatory support, blankets, r/o infection
Not a thyroid illness, but marked by thyroid lab abnormalities caused by serious general illness.
Dx and treatment?
SICK EUTHYROID SYNDROME
-Dx= low free T3 and high "reverse" T3
-Does not require therapy (except treatment of underlying illness)
nUse of this drug for multiple sclerosis may lead to thyroid autoimmune disease like Graves' disease years later.
your patient has thyroid nodules. What is the stepwise approach to diagnosis?
-1ST Step: check TSH to r/o "hot" or overactive nodule
-OK to order I-123 scan/uptake if nodule is "hot"
-2nd Step: refer to Endocrinologist for FN Aspiration if nodule not "hot", or Tx of hyperthyroidism if "hot"
MC type of thyroid carcinoma?
Treatment Modalities for Thyroid Cancer
-radioactive therapy and chemo
nA 55 yo female presents with lethargy, fatigue, constipation, & menorrhagia. Exam shows enlarged thyroid, dry skin, heart rate 50. Lab shows low free T4 and high TSH. Most likely diagnosis is:
A. secondary hypothyroidism.
B primary hypothyroidism.
C. primary hyperthyroidism
D. secondary hyperthyroidism.
B primary hypothyroidism.
In what respect is treatment of secondary hypothyroidism the same as treatment of primary hypothyroidism --- and in what respect is it different?
-in secondary, it's due to pituitary issues so there are probably OTHER hormone problems going on also and we need to figure out if there are
If you see a patient where the total T4 test suggests abnormal thyroid function and the T3-resin test suggests the OPPOSITE extreme of thyroid dysfunction, what comes to mind?
- There is a problem with a thyroid binding protein, not dysfunction of the thyroid itself
nA 27 y.o. female sees her doctor because of her concern over a 10 lb weight gain over the last 3 months. She admits to some fatigue, but cares for her 2 children ages 2 yrs & 4 yrs. No temp intolerance, palpitations, tremor, or dry skin. Thyroid tests show a hi T4 of 15 mcg/dL (normal 5-11) and a low T3-uptake of 14% (normal 20-30). What is her thyroid status? How would you document further?
She has a high T4 and low T3, so she has a protein binding abnormality.
Check a TSH, free serum thyroxin, etc. to see if she actually has a normal amount of thyroid hormone
A 31 y.o. female pregnant at 15 weeks complains of feeling hot, sweaty, shaky, and has palpitations. Exam & lab tests confirm thyrotoxicosis. What would you treat her with?
nA. methimazole or PTU
nB. radioactive iodine
D. a beta blocker
A.typical thyroid pills low dosage
nA 40 y.o. male with a history of dry skin, fatgue, weight gain, and cold intolerance was found to have primary hypothyroidism. He complains to you that his symptoms persist even though he has been using his medication l-thyroxine for a full week . At this point, you would...
Takes 6 weeks for levothyroxine to work/ before changing dose so this pt needs to wait
Case 4 NOT ON PPT but on his:
45 yo female has primary hypothyroidism. declined treatment w I-thyroxine and wants natural medicine. specifically old fashioned desiccated thyroid.
2 mos later she feels better, but seeing you bc she had T3 on her lab test
didnt hear the answer:( Maybe factitious disease
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