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Thyroid Disorders
Clinical Medicine II
| Question | Answer |
|---|---|
| Fxns of the thyroid gland | hormone regulation, secretes thyroid hormone, homeostatis of metabolic/thermogenic processes |
| Anatomy of the thyroid gland | 2lobes R larger, and isthmus |
| What comes from the hypothalamus and ant pit | H: Thyrotropin-releasing hormone (TRH), A: Thyroid-stimulating hormone(TSH): diurnal rhythem |
| What triggers TRH | cold exposure, stress, low T4 levels |
| Fxns of TSH on the thyroid gland | ↑ release of TH, ↑ iodine uptake/oxidation, ↑ TH synthesis, ↑ synthesis/secretion of prostaglandins |
| The does TH do | ↑ -FB and inhibits more TRH and TSH |
| Primary, secondary, tertiary causes of hypothyroidism | 1: thyroid gland itself, 2: ant pit tertiary: hypothalamus |
| What stimulates TH production | TSH, ↓ serum idodide, medications w/ iodide uptake |
| What is required to make TH | thyroglobulin |
| 3 carrier proteins | TBG, TTR (transthyretin), Albumin |
| How do we make T4 | Coupling of two DIT (Thyroxine) More common, and converted to T3 in tissues |
| MIT and DIT | monoidotyrosine, and diiodotyrosine |
| What makes MIT and DIT | iodine + tyrosine: iodotyrosines |
| How do we make T3 and name | Triodothyronine: Coupling of DIT and MIT (not as much produced, 20 %) |
| Which form is more active and when | T3 more active tho less, and is active when UNBOUND important when doing thyroid tests |
| #1 test for thyroid tests | TSH nl: 0.34-4.25 IU/mL |
| #2 or back up thyroid tests | Free T4 nl: 0.7-1.24 ng/dL |
| How does thyroid effect Ca++ levels | releases calcitonin which effects osteoclasts/reabsorption changes, minimal effect globally though, but important w/ thyroid cancers |
| What is important during H&P | any problems w/ neck, trauma, FHx, any previous radiation etc, (bruit in thyroid) |
| What is thyrotoxicosis | hyperthyroidism: ↑ circulating TH |
| Over active thyroid hormone | hyperthyroidism |
| Thyrotoxicosis | ↑ presence of circulating TH |
| What is thyrotoxicosis factitia | “false” hyperthyroidism 2nd to exogenous replacement from hypothyroidism |
| Cuases of hyperthyroidism | Graves’, Toxic multinodular goiter, toxic adenoma, carcinoma, pituitary adenoma, throyditis, factitia |
| Sequelae of hyperthyroidism | ↑ CV morbidity/mortality, so A fib, CHF, angina/MI/sudden death, osteoporosis |
| Endocrine SE’s | Goiter, bruit, hypercalcemia, ↓ PTH, secretion, insulin resistance |
| Neuro SE’s | fatigue, restlessness, tremor, insomnia, emotional lability, DTR |
| GI SE’s | Wt loss, ↑ appetitie, diarrhea, pain, N/V/ ↓ lipids |
| Eyes SE’s | ↓ blinking, lid tremor, infiltrates |
| CV SE’s | ↑ CO, ↓ peripheral resistance, tachy, SVT, LVH |
| Pulm SE’s | Dyspnea, ↓ vital capacity |
| Reproductive SE’s | oligomenorrhea, abnl menstral cycles in general ( not ↑ or ↓) |
| Most common SE’s | goiter, fatigue, wt loss, sweating, |
| Evaluation of hyperthyroidism | TSH then FT4, then T3, then radionuclide uptake scan |
| Sings of primary HEY | Thyroid Gland origination: ↓ TSH/TRH |
| Labs of secondary HEY | Ant Pit: Low TRH, High TSH, and T3,T4 |
| Labs for Tertiary HEY | hypothalamus: all levels are elevated |
| MC hyperthyroid dx | Graves’ disease: autoimmune effect the Thyroid gland itself |
| Organs systems effected | thyroid gland, goiter, ophthalmopathy, dermopathy |
| Epidemiology of Graves’ | Women>>Men (<1% total population) |
| Assocaitions of Graves’ | associated w/ other autoimmune disorders, Type 1 DM, vitiligo, pernicious anemia, collagen vascular dzs |
| Patho of grave’s | antibodies against antiperoxidase so doesn’t stop the making of TH |
| Why do we get goiter | ↑ iodine uptake and vascularity |
| Sxs of graves’ | diplopia, blurred vision, lacrimation, photophobia, heat intolerance, tachy, eye dryness |
| Signs of graves’ | pretibial myxedema (dermopathy), exophtlalmos, lid lag, EOM paralysis, brisk DTRs, periorbital edema, papilledema, Goiter, |
| Is the goiter tender | NO! |
| What is lid lag | looking down, seeing the sclera above the iris |
| MC reason for hyperthyroidism | Graves’ |
| Sudden, SEVERE, thyrotoxicosis | thyroid storm |
| Causes of thyroid storm | trauma, surgery, infection, ongoing dz |
| Will this cause death? | yes! Fatal cardiac manifistations |
| Sxs of thyroid storm | dramatic, fever, severe tachy, delirium/coma |
| Reasons for thyroid storm | usually underlying problem, but precipitating factor causes massive release of TH |
| Enlargement of the gland | multinodular goiter |
| Etiologies for multinodular goiter | hypothyroid/ ↑ TH needs, iodine deficiency, infectious or genetic d/o |
| Effects of multinodular goiter | hormone levels vary, eu or hyperthyroid, |
| What ↑ chance for multinodular goiter | age, women>>men |
| Tx for multinodular goiter | observation? If asymptomatic, radioactive iodine ablation (131I most common) |
| When do we do surgery | compressive sxs, large gland, refuses iodine tx |
| Diff b/w multinodular and thyroid nodules | TN usually just single nodule or adenoma |
| Sxs of TN | usually gradual, rare to find eye or skin involvement, often asymptomatic |
| Hot nodule | uptake iodine more then normal (usually not worried about it) |
| Cold nodule | doesn’t uptake iodine as much, more likely (still rare) to be cancer |
| Scans for Hot/cold nodules | RAIU scan 121I most common |
| Eval for thyroid nodules | ultrasound, RAIU scan, biopsy common |
| Inflammation w/ the thyroid gland | subacute thyroiditis usually d/t viral infx |
| Problems w/ thyroiditis | follicular cell damage, elevated TH initially, then eu then hypo, must monitor for longer periods of time |
| Pattern of thyroidits | hyperthyroid, euthyroid, hypothyroid |
| Hallmark of thyroiditis | tender gland, or sore throat |
| Mc elevated primary hyperthyroidism | elevated Free T4, T3 toxicosis possible |
| What is present w/ graves’ disease | IgG thyroid autoantibodies |
| Tx for hyperthyroidism | antithyroid drug therapy, radioactive iodine, subtotal thyroidectomy, adjuvant symptomatic tx |
| Which tx is CI in pregnancy | radioactive iodine, MUST stay away for a few days post tx |
| What often leads to hypothyroidism | radioactive iodine d/t kill too many thyroid cells |
| Adjuvant symptomatic tx | cardiac sxs: B-blockers, iodine: block release of further thyroid hormone usually prior to surgery or emergent situations, corticosteroids and NSAIDS, will suppress TSH levels, artificial tears: Graves; epthomology |
| MC hypothyroidism | autoimmunie Hashimoto’s thyroiditis |
| Causes of hypothyroidism | hashimoto’s thyroiditis, subacute thyroiditis, silent thyroiditis, postpartum thyroiditis, post-therapeutic (to hyperthyroidism) |
| Primary causes of TH def | autoimmune, loss of thyroid tissue, iodine def, anti-thyroid drugs |
| Secondary causes of TH def | pituitary insult |
| Tertiary causes of TH def | anorexia, hypothalamic tumors |
| Sxs of hypothyroidism | fatigue, cold intolerance, dry, constipation, facial swelling, puffiness, DTR relaxation delayedness |
| How do bodies run temp wise in hyper and hypo thyroidism | hyper: run hot hypo: run cold |
| Sxs and tx for subacute thyroiditis | sxs last 2-4 months, tx the sxs if hyper or hypo, and tx not always necessary |
| painless thyroiditis | clinically like hashimoto’s, tx like TH def, give TH, but will resolve on their own |
| two types of painless thyroiditis | silent and postpartum: postpartum usually 3-6m after delievery, sometimes ~50% remain hypothyroid |
| chronic lymphocytic thyroiditis | hashimoto’s thyroiditis W/M |
| mean age of hashimoto’s | 60 |
| abs associated w/ hashimotos | thyroglobulin, thyroid peroxidase, TSH receptor |
| genetic predisposition to hashimoto’s | it happens |
| Iatrogenic cause of hypothyroidism | post-therapeutic hypothyroidism secondary to RAI (usually tx of hyperthyroidism especially in cancer): thyroidectomy |
| Causes of goiter | I deficiency, constant TSH stimulation or iodine trapping, |
| Why don’t we see goiter as much in the U.S. | use of iodized salt |
| Mc congenital hypothyroidism | cretinism |
| If we have a goiter what does that mean w/ thyroid levels | nothing, hyper and hypo and eu TH can see a goiter |
| What is cretinism | congenital hypothyroidism found in severely deficient areas, major cause of MR |
| Clinical syndrome found in acutely ill patients | euthyroid sick: challenging to diagnose |
| Dx of euthyroid sick | ↓ total and unbound T3, nl T4 and TSH therefore making it diagnose, can initially see elevated T3 and or T4 |
| Untreated but long standing complication of hypothyroidism | myxedema coma |
| S/S of myxedema coma | extreme hypothermia, arelexia, szs, CO2 retention, brady, widespread edema, res ↓, coma |
| Where do we see myxedema coma | MC in elderly |
| Thyroid hormone preperations | synthetic T4 preparation (L-thyroxine) F/U every 6-8weeks until WNL, annual once nl |
| MC endocrine cancer | thyroid cancer |
| Dx of thyroid cancer | FNA fine needle aspiration biopsy of a nodule |
| MC thyroid cancer | papillary carcinoma |
| Characteristics of papillary carcinoma | mets to lymph nodes, young 20-40, LT survival/cure rate excellent |
| Tx of thyroid cancer | Surgery, 131 I then 123I after, complete TSH suppression |
| Diagnostic tests for thyroid d/o | thyroid US for nodules and cysts, also aids in biopsies, FNAB: malignancy, RAIU: 123 I absorption Hot: ↑ uptake cold ↓ uptake more worrysome for cancer |
Created by:
becker15
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