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Thyroid Disorders

Clinical Medicine II

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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