1
Q
Thyroid Hormones
-Physiologic Effects
A
Thyroid hormone helps every body cell regulate metabolism
- Affects fetal development
- Regulates O2 consumption and heat production
- Affects CV muscle contraction
- StimulatesBone resorption
- Permits normal glucose metabolism ,absorption, and storage
- Functions in the synthesis and breakdown of lipids
- Affects rate of metabolism of many hormones and drugs
2
Q
Thyroid Hormones
-Heat Regulation?
A
- Hypothyroidism patients report increased sensitivity to COLD
- Hyperthyroidism patients report increased sensitivity to HEAT
3
Q
Thyroid Glad
-Endocrine System
A
- Regulated by Thyroid stimulating hormone (TSH)
- Thyroid glad produces
- Triiodothyronine (T3)
- Thyroxine (T4)
4
Q
Thyroid Disorders
-Stats
A
- 20 million Americans affected with 60% unaware of their condition
- Women are 5-8x more likely than men to have thyroid problems
- Undiagnosed Thyroid dz can lead to risk for
- CVD< osteoporosis, and infertility - Most Thyroid Dz are LIFE-LONG conditions
5
Q
Thyroid Disorders
-Undiagnosed Hypothyroidism in Pregnancy
A
- Undiagnosed hypothyroidism in pregnant women leads to:
- Miscarriage
- Preterm delivery
- Severe developmental problems
6
Q
Thyroid Regulation
-Hypothalamic-Pituitary-Thyroid Axis?
A
- Hypothalamus Produces “Thyroid Releasing Hormone”
- TRH is MAIN HORMONE that regulates thyroid gland - TRH stimulates the anterior pituitary to produce Thyroid Stimulating Hormone “TSH”
- TSH stimulates thyroid glad to secrete T3 and T4 from pituitary gland
- TRH and TSH are negative feedback relationship
- Too much hormone can lead to hyperthyroidism
- Too little hormone leads to hypothyroidism
7
Q
Abnormalities of Thyroid Gland
-Types?
A
- Structural & Functional abnormalities
- Cysts
- Nodules
- Overactive or under-active thyroid
- Cancer
8
Q
Structural & Functional Abnormalities of the Thyroid
A
- Goiter’s are the MOST COMMON structural abnormality of the thyroid gland
- Enlargement of the thyroid - Tumors (Nodules)
9
Q
Structural & Functional Abnormalities of the Thyroid
-Characteristics
A
- Asymptomatic
- Hyperthyroid or hypothyroid symptoms
- Neck swelling
- Airway compression
- Difficulty swallowing
10
Q
Structural & Functional Abnormalities of the Thyroid
-Thyroid Nodules
A
- Abnormal overgrowth of tissue
- Can be filled with liquid or solid
- Classified as hot, warm or cold according to amount of iodine isotope in the nodule compared to amount in the rest of the thyroid gland
- Hot Nodules are benign
- Cold Nodules can be malignant - Often Asymptomatic
- Iodine deficiency regions are impacted
- More likely in women w/ advancing age
11
Q
Structural & Functional Abnormalities of the Thyroid
-Hot Vs. Cold Nodules
A
- Hot Nodules are benign
- Cold Nodules can be malignant
Nodules are usually asymptomatic; monitor for ANY changes
12
Q
Structural & Functional Abnormalities of the Thyroid
-Thyroid Cysts
A
- Thyroid cysts are nodules that contain LIQUID
- Usually benign or non-cancerous
- May be asymptomatic or c/o
- Difficulty breathing, swallowing or vocal changes - May reoccur after draining
13
Q
Structural & Functional Abnormalities of the Thyroid
-Complex cysts or mixed Echogenic Nodules?
A
- Have both liquid and solid components
2. Could be cancerous
14
Q
Structural & Functional Abnormalities of the Thyroid
-Tests for Thyroid Cysts
A
- Ultrasound
- Biopsy (Refer to specialist for US guided procedure)
- Thyroid Scan
- Suspicion if cyst is secreting hormones
- If cyst is producing hormone, it is ACTIVE and can cause HYPERTHYROIDISM
15
Q
Structural & Functional Abnormalities of the Thyroid
-Thyroid Scan Test
A
- Radioactive Iodine Pill given to Patient to help track iodine as it moves through thyroid gland
- SHOULD NOT be performed on pregnant or nursing mother
16
Q
Structural & Functional Abnormalities of the Thyroid
-Goiter
A
- Abnormal enlargement of the thyroid gland
- D/T inflammation of thyroid gland or iodine deficiency - May be Asymptomatic
- Iodine deficiency
- May occur in hyper, hypo, or euthyroid states
S/S
Swelling, cough, dyspnea, throat tightness and hoarseness
17
Q
Structural & Functional Abnormalities of the Thyroid
-Goiter Patho
A
- Increased signaling of TSH receptor to produce MORE hormone
- Ignoring feedback system - Leads to hypertrophy of the gland
-In Hypothyroid state
—(Body realizes there is lack of hormone and increases TSH)
-In Hyperthyroidism
—(Excess stimulation of TSH receptors even w/ normal hormone levels
18
Q
Structural & Functional Abnormalities of the Thyroid
-Risk Factors
A
- Heredity
- Female Gender
- Age over 40
19
Q
Structural & Functional Abnormalities of the Thyroid
-Conditions That can cause a Goiter?
A
- Graves Dz (Autoimmune)
- Hashimoto’s Dz (Autoimmune)
- Nodular Goiter
- Thyroiditis
- Thyroid Cancer
- Exposure to radiation
20
Q
Hyperthyroidism
-Definition
A
-Hyperthyroidism is a clinical syndrome caused by:
1. Excess production OR release of thyroid hormone
AND
2. Clinical manifestations
21
Q
Hyperthyroidism
-Classifications (3)
A
- Primary Hyperthyroidism
- Independent of TSH - Secondary Hyperthyroidism
- TSH-Dependent - Tertiary Hyperthyroidism
- TRH-Dependent
22
Q
Hyperthyroidism
-Primary Hyperthyroidism
A
- Independent of TSH
23
Q
Hyperthyroidism
-Secondary Hyperthyroidism
A
- TSH-Dependent
24
Q
Hyperthyroidism
- Tertiary Hyperthyroidism
A
- Thyroid Releasing Hormone TRH-Dependent
25
Hyperthyroidism
| -Common Causes
1. Graves Dz
2. Subclinical Hyperthyroidism
3. Thyroiditis
- Subacute thyroiditis (Post-viral illness, tender)
- Silent Thyroiditis (Autoimmune, painless)
26
Hyperthyroidism
| -Cause-Thyroiditis (2 types)
1. Subacute Thyroiditis (Postviral illness, Tenderness)**
| 2. Silent Thyroiditis (Autoimmune, Painless)**
27
Hyperthyroidism
| -Graves Dz
1. Accounts for 60-80% of all types of hyperthyroidism (MOST COMMON)
2. AUTOIMMUNE causing hyperfunction of thyroid
3. Higher in women (7:1) and ages 20-40 highest age group
28
Hyperthyroidism
| -Graves Dz Thyroid Function Test Results?
1. Increase in Free T4, and T3
| 2. Decrease in TSH
29
Hyperthyroidism
| -Graves Dz Symptoms
1. Exophthalmos
2. Signs of increased metabolism (sweating, increased HR, nervous, weight loss, tremors, etc)
3. Nausea and diarrhea
4. Goiter
5. Oligomenorrhea
30
Hyperthyroidism
| -Graves Ophthalmopathy
1. Bulging eyes
2. Pressure or pain
3. Double vision, light sensitivity
4. With progression of dz, vision loss can occur
31
Hyperthyroidism
| -Graves Dermopathy
1. Reddening of the skin, most often on shins or top of the feet*
32
Hyperthyroidism
| -Diagnostic Testing
1. TSH — BEST screening for hyperthyroidism
- In hyperthyroidism, TSH will be low or undetectable
2. Free T4 will show the extent of Dz
3. TSH and Free T4 most often drawn in primary care
4. Thyroitropin receptor antibody (ELEVATED)
5. ESR — Elevated in subacute thyroiditis w/ tenderness noted due to post viral illness*
6. Radioiodine (Differentiate Graves from Thyroiditis) (ID a toxic multinodular goiter)
7. Magnetic Resonance Imagining (Adeloma’s best visualized on MRI)
33
Hyperthyroidism
| -Management Goal?
1. Euthyroid state**
2. Minimize adverse effects of treatment
3. Decrease incidence of iatrogenic hypothyroidism
34
Hyperthyroidism
| -Pharmacologic Management of Graves Dz?
```
Consider Cause of DZ and Pt’s age
1. Beta-blocker Therapy **
-BB help treat the alpha Adrenergic symptoms of hyperthyroidism (Ex: Tachycardia & tremors)
—Propranalol 10-40 mg PÓ q6h
—Atenolol 25-100 mg daily
```
2. Adjust dose to keep HR between 60-90
3. Use w/ CAUTION in CHF, Bronchospasm, Pregnancy
35
Hyperthyroidism
| -Thioamide Therapy
1. Check BASELINE CBC and LFT before initiating treatment
2. Methimazole (MMI, Tapazol, Not for 1st Trimester Pregnancy)
3. PTU — Do not use as first line d/t risk of liver failure
—PTU is drug of choice during pregnancy esp 1st trimester
4. Pt’s may go into remission 6-12 months after thioamide therapy
-If pt relapses, treat with radioiodine ablation
36
Hyperthyroidism
| -Thioamide Therapy Side effects?
1. Jaundice
2. Pruritic rash
3. Arthralgias
4. Risk of agranulocytosis
37
Hyperthyroidism
| -Medical Therapy 1
Medical therapy is treatment of choice for:
1. Patients <20 yrs old
2. Pregnant women
3. Patients likely to go into remission
38
Hyperthyroidism
| -RadioIodine Therapy
Treatment of choice in US for:
1. Patients >20 yrs old
2. Failure on Thioamides
DO NOT use Radioiodine therapy when:
1. Patient is pregnancy
2. Avoid in patients with Graves Ophthalmopathy
39
Hyperthyroidism
| -RadioIodine Therapy Monitoring
1. Monitor TFT 4-6 wks after treatment for evidence of hypothyroidism
2. If hypothyroidism is not present, monitor TFT MONTHLY for 3-4 months and then periodically.
40
Hyperthyroidism
| -Thyroidectomy
Recommended for:
1. Pregnant women and patients who cannot be managed on thioamides
2. Pt’s who refuse radioiodine therapy
3. Patients w/ obstructive goiter
41
Hyperthyroidism
| -Thyroidectomy Complications
1. Hypothyroidism
2. Hypo-parathyroidism
3. Hoarseness (D/t nerve damage
S/P Thyroidectomy, pt’s will need LIFELONG treatment
42
Hyperthyroidism
| -Consults and Referrals
1. Consult Endocrinologist for:
- Graves Ophthalmopathy
- Radioiodine Therapy
2. Consult Ophthalmologist
- Graves Ophthalmopathy
43
Hyperthyroidism
| -Untreated Graves Dz Leads to?
If left untreated, graves dz can lead to the following
1. A-fib
2. CHF
3. Angina
4. Osteoporosis
44
Hyperthyroidism
| -Thyroid Storm
Rare, life threatening complication of hyperthyroidism w/ symptoms including:
1. Elevated temp 102-105F
2. Profuse sweating, tachycardia, HTN, Afib, agitation, confusion, restlessness, coma, and Diarrhea
Life Threatening
45
Hyperthyroidism
| -Subclinical Hyperthyroidism
1. Most cases are a result of autonomously functioning thyroid nodules & multinodular goiters
2. Most elderly Pt’s w/ subclinical Hyperthyroidism have multinodular goiters
3. Afib risk is related to DEGREE of TSH suppression
46
Hyperthyroidism
| -Subclinical Hyperthyroidism Lab Finding
1. TFT shows suppressed TSH
AND
2. Normal serum T4 and T3 levels
47
Hyperthyroidism
| - Thyroiditis
1. Tender thyroid gland (may also present subacute or painless)
2. Recent viral illness
3. Treat symptomatic hyperthyroidism w/ beta blockers
4. Pain relief w/ NSAIDS, ASA x2-3 days
5. If pain continues, DC NSAIDS and start prednisone 40mg daily until pain relief
- Taper prednisone by 5-10 mg for the next 5 days. DO NOT stop abruptly
48
Hyperthyroidism
| -Painless Postpartum Thyroiditis
1. Treat hyperthyroid state w/ beta-blockers (Caution d/t med passing through breastmilk)
2. Initiate therapy if hypothyroid state is severe
3. Monitor TFT
4. May reoccur w/ subsequent pregnancies
49
Hyperthyroidism
| -Toxic Nodule Management
1. Treatment of Choice is:
| - Radioiodine ablation after beta-blocker therapy**
50
Hyperthyroidism
| -Toxic Multinodular Goiter Management
1. Start w/ beta blocker therapy
| 2. Radioiodine ablation is TREATMENT OF CHOICE**
51
Hyperthyroidism
| -Patient Education
1. Review Symptoms which may mimic mental health problems
2. Review Thyroid storm symptoms
3. Monitor Pulse when on BB
4. Serious effects os agranulocytosis if on thioamides (Chills fever…)
5. Follow up in 4-6 wks (Med adherence)
-Hypothyroidism may result from therapy
6030 Primary Care Test 2 Complete ☑️
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