ࡱ> GIF@ !bjbjFF ":,,2222222F$<F=2$oR2)))22ccc) 22c)cc@22  pPa3 X 0=`,M=MFF2222M200F"chFFdY FFThyroid Disorders Thyroid physiology Thyroid gland Bilobar structure in the neck Moves up upon swallowing Has many thyroglobulin containing hair follicles Function is to produce and store thyroid hormone Must have iodine to produce thyroid hormone(100-200mg/day) Iodine is pumped into follicular cells, it is oxidized by peroxidase and facilitates the combination of tyrosine molecule from the thyroglobulin and forms either mono- or di-iodotyrosine When two of the di-iodotyrosine combines we get T4. When a mono- and a di-iodotyrosine combine we get T3 Negative feedback axis Hypothalamus- thyroid releasing hormone Anterior pituitary- thyroid stimulating hormone Thyroid- T3, T4 The major thyroid hormone in circulation is T4 Converted into T3 in the periphery 2 major functions of the thyroid hormone Increase metabolism and protein synthesis Necessary for growth and development and maturation of intelligence in children All major organs are affected by altered levels of thyroid hormone Varied symptoms Hypothyroidism Can be congenital or acquired Newborns are screened Congenital Preventable cause of mental retardation and impaired growth Can be secondary to lack of thyroid gland, abnormal biosynthesis of thyroid hormone or deficiency in TSH Prompt treatment with T4 necessary Primary hypothyroidism Chronic autoimmune thyroiditis (AKA hashimotos thyroiditis) Have high serum autoantibodies to thyroglobin occurs mostly in older females Cell and antibody destruction of thyroid tissue Iatrogenic Thyroidectomy- 2-4 weeks post Iodine treatment Mos. To years after Radiation- dose related Iodine deficiency Most common cause of hypothyroidism worldwide Rare in US Drug induced PTU, methimazole, lithium, amiodarone- cause decrease in production of T3 and T4 High doses of iodine- very high Postpartum thyroiditis Usually preceded by period of hyperthyroidism Usually resolves after 6-12mos. Signs and symptoms Vary in relation to the magnitude and acuteness of hormone deficiency Slowing of the metabolic process May complain of the following Fatigue, constipation, cold intolerance, SOB, decreased taste, weakness, slow movement, slow speech, weight gain, hair loss, decreased sweating On PE you may note: Delayed DTR, macroglossia, bradycardia, cool/pale skin, loss of lateral 1/3 of eyebrows, puffiness of face/eyelids, poor skin turgor, coarse hair, non-pitting edema, hoarseness, hair loss, thin/hair brittle nails, goiter Diagnosis Lab findings Low to normal T4 level Elevation of TSH(most sensitive test) Other lab abnormalities Hypercholesterolemia Anemia Treatment Hypothyroidism is a permanent condition************************ Goal of treatment is to replace thyroid hormone Oral administration of synthetic thyroxine (T4) Levothyroxine (Synthroid) Titrate dose every 4-6 weeks until TSH normalizes Start low and increase until desired level is reached Myxedema Coma Severe hypothyroidism Decreased mental status, hypothermia, and cardiovascular collapse Can be from long standing hypothyroidism or can be triggered by infection, MI, narcotics, extreme cold Usually in the elderly, especially female Hypotension, bradycardia, hyponatremia, hypoglycemia, hypoventilation, hypothermia, It is a medical emergency Check TSH and T4 Treat on clinical suspicion Treat with warm, glucose and the underlying cause Hyperthyroidism Results from excessive delivery of thyroid hormone to periphery Causes Graves disease MCC of hyperthyroidism Autoimmune Females ages 20-40 Hyperthyroidism, goiter, exophthalmus Radioiodine scan will show increased uptake Toxic multinodular goiter Diffuse hyperplasia of thyroid follicular cells T3, T4 produced independent of TSH Increased uptake on radioiodine scan Subacute thyroiditis Inflammation of thyroid tissue with transient hyperthyroidism due to release of performed hormone Common after pregnancy ( becomes hypothyroidism) Other rare causes High levels of iodine intake Amiodarone, contrast agents TSH secreting pituitary tumor Ovarian dermoid tumors containing thyroid tissue Signs and symptoms Anxiety, weakness, increased appetite, tremor, hyperdefecation, urinary frequency, erectile dysfunction, thinning hair, emotional lability, increased perspiration, weight loss, palpitations, heat intolerance, muscle weakness, oligomenorrhea On PE Hyperactivity, warm/moist skin, exophthalmus, lid lag, goiter, softening of nails, rapid speech, tachycardia, stare, hyperreflexia, pretibial myxedema (small nodules), atrial fibrillation Diagnosis Laboratory findings Decreased TSH Increased T3, T4 Radioactive iodine uptake Treatment Thionamides Inhibit thyroid hormone synthesis by the gland Prophylthiouracil (PTU) and methimazole Attain euthyorid state in 3-8 weeks Beta blockers Ameliorate symptoms such as palpitations, anxiety, tremor Propanolol is the agent of choice Radioiodine ablation Treatment of choice in US Sodium 131 1 PO, rapidly concentrated in thyroid tissue Leads to extensive tissue damage, ablation of thyroid in 6-18 weeks Thyroidectomy- must take synthroid or it will turn into hypothyroidism Unpopular in the US Used for very large or obstructive goiter Thyroid Storm Severe life threatening hyperthyroidism (thyrotoxicosis) Exaggerated symptoms Tachycardia, hyperpyrexia, agitation, CHF, delirium, psychosis, stupor, coma Can be seen in patient with long standing hyperthyroidism but usually triggered by an acute event Medical emergency Treated with a beta blocker and high dose methimazole Thyroid Cancer Relatively uncommon diagnosis Favorable prognosis 1% of all cancer diagnosis Females affected more often than men Radiation exposure increases risk of development Types Papillary- most common Slow growing, best prognosis Follicular- 2nd most common Slightly more aggressive than papillary Medullary Poorer prognosis than papillary and follicular Associated with MEN 2a, 2b Anaplastic Rapidly growing, poor prognosis Signs and symptoms Painless, palpable solitary thyroid nodule Discovered by patient or healthcare provider on routine palpation of the neck Hard, fixed nodules more suspicious for malignancy May have anterior cervical lymphadenopathy Solitary Thyroid Nodule More likely malignant in patients < 30y.o. or more than 60y.o. Multiple nodules are usually benign Diagnosis Thyroid tests are usually normal Fine needle aspiration biopsy (FNAB) Best way to asses for malignancy Performed with a 25 gauge needle Radioactive iodine scan-not specific Less useful than FNAB Cold spots- doesnt take up iodine, usually malignant Hot spots- usually benign Ultrasound   B N j | $ % N O  ! ] ^ CJTUjxy "#qhĻĻĻğğĻĻĻĻėhq;CJaJh_CJaJh_5CJaJh7ih7iCJaJh7i5CJaJh7iCJaJh7ih65CJaJh6h65CJaJh6h6CJaJh65CJaJh6CJaJ:%3Qj + B j % O  6 B  & Fgd6 & Fgd6 & Fgd6 & Fgd6!B ~ ! ^ +CU #Qq  & Fgd7i & Fgd7i & Fgd7i & Fgd6 ] ?Mc 6 & Fgdq; & Fgdq; & Fgdq; & Fgdq; & Fgdq; & Fgd7i+D\] >LMbc  56TUl  <=`a-.@\]xyººhrhr5CJaJhrCJaJhr5CJaJhq;h_5CJaJhq;hq;5CJaJhq;CJaJhq;hq;CJaJhq;5CJaJDU\l =a.@]y & Fgdr & Fgdr & Fgdr & Fgdq; & Fgdq; & Fgdq; & Fgdq;,-TUxyIJ!JXYZnoeu5QR_¹±¹±¹ڱ±±±¹±±±±¹¹hcCJaJhc5CJaJhchc5CJaJhchr5CJaJh_CJaJhrCJaJhr5CJaJhrhr5CJaJC-UyJ & Fgdc & Fgdc & Fgdr & Fgdr & Fgdr!Zo0fu5Rn*U & Fgdc & Fgdc & Fgdc & Fgdc_an *<TU   X Y | } !!4!5!J!!!!!ĬĬĬĬhchr5CJaJh_h_5CJaJh_hc5CJaJh_CJaJh_5CJaJhchc5CJaJhcCJaJhc5CJaJhchc5CJH*aJ)  Y } !5!K!!!!! ^ gdr & Fgd_ & Fgd_ & Fgd_ & Fgdc & Fgdc 1h/ =!"#$%@@@ NormalCJ_HaJmH sH tH DA@D Default Paragraph FontRiR  Table Normal4 l4a (k(No List:%3Qj+Bj%O 6B~ !^+CU #Qq    ] ? 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