thyroid disorders · 2018. 10. 30. · toxic multinodular goiter toxic adenoma. graves disease •...
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Thyroid disordersDr Enas Abusalim
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Thyroid physiology
• The hypothalamic –pituitary –thyroid axis• And peripheral conversion of T4 to T3 , WHERE , AND BY WHAT
ENZYME ??• Only relatively small concentrations of T4 and T3 are biologically
active , WHY ?• WHAT IS THE DAILY REQIUREMENT OF IODIDE IN ORDER TO
MAINTAIN NORMAL THYROID FUNCTION ?
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Common presentations in thyroid diseases
• Enlargement of the thyroid gland ( goiter ),• Incidental finding of abnormal thyroid function test ,• Symptomatic hypothyroidism or hyperthyroidism .
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Who should be tested for abnormal thyroidfunction ?
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Who should be tested for abnormal thyroidfunction ?
• Patients with signs and symptoms of either hypothyroidism orhyperthyroidism , WHICH ARE ?
• All pregnant patients as a routine screen during booking visit ,• Goiterous enlargement of thyroid gland ,• In the presence of other autoimmune diseases ( INCLUDING ………….
???)• As follow up post thyroid resection , or thyroid cancer treatment .
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Hyperthyroidism
• What is THYROTOXICOSIS ??• How does it differ from the term hyperthyroidism ?• What are the causes of hyperthyroidism ? Most common ?
Graves diseaseToxic multinodular goiterToxic adenoma
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Graves disease
• An autoimmune disorder• Affecting the thyroid gland ( hypersecreting and goiterousenlargement ) , periorbital fat ,ocular muscles ( proptosis , diplopia ,
chemosis ophthalmoplegia ) , and skin ( pretibial myxedema ) .• Caused by antibodies against which receptor ?????• Can Graves ophthalmopathy occur in a euthyroid individual ?• Family history of autoimmune thyroid disease often present , and is a
risk factor for the development of Graves .
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What does physical examination of the thyroidgland reveal in Graves Disease ?
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Diagnosis
• TSH level is the first step inpatient who present with signs andsymptoms of abnormal thyroid function .
• Normal range is variable according to age , pregnancy , but is usuallybetween 0.4-4 milli-international units /L in young non-pregnantpatients .
• If abnormal this should be followed by measurement of T4 levels (not T3 , WHY ??)
• Normal range of T4 is 4.6-12 ug/dl• Anti –TSH receptor antibodies ( TSI , TBII )• WHAT IS NEXT ?
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For any patient with signs and symptoms of hyperthyroidism,and abnormal thyroid function test , the next step is a RAIUscan .How is it beneficial????
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Treatment of hyperthyroidism• For Graves disease treatment options are :✓ Antithyroid drugs ,✓ Radioactive iodine ablation of the thyroid gland , ( any contra-indications ?? ).✓ And thyroid surgery .
In addition to symptomatic relief by beta-blocker therapy to suppress excessadrenergic tone ( propranolol for example , which has the additional benefit OF ???)
• How should treatment be monitored after initiation of management ??• What is the expected outcome of radioactive iodine ablation of the thyroid gland
in graves disease ??
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Treatment of multinodular goiter andsolitary thyroid nodule
• What is the gold standard treatment option , and how does it differfrom treatment of graves disease post treatment ???
• What is Jod-Basedow phenomenon ?• What are the indications of thyroidectomy in a hyperthyroid patient
??• If a cold thyroid nodule was found in a RAIU can for multinodular
goiter what would be your next best investigation ?
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Hypothyroidism
• The most common cause is ??? Other causes ??• Name possible medications known to cause hypothyroidism ??• How does an associated coeliac disease effect the management of a
hypothyroid patient ?
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Hashimotos thyroiditis
• An autoimmune disorder caused by antibodies against TPO ,andthyroglobulin .
• Signs and symptoms ??• How does it affect blood pressure and lipid profile ?• Tendon reflexes ??• Is RAIU scan required ?• Is an Ultrasound required ?
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Treatment of hypothyroidism
• Levothyroxine therapy is the mainstay of thyroid hormonereplacement ,
• What are the precautions you must inform your patient about whiletaking thyroid replacement therapy ??
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Destructive thyroiditis
• Definition :• Types :1- Subacute thyroiditis2-Silent thyroiditis3-post partum thyroiditis
• Diagnosis :• Treatment :
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Thyroid EMERGENCIES !!!
Thyroid StormAnd myxedema Coma
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Thyroid Strom• This is a life threatening condition presenting as1- severe thyrotoxicosis 2- coupled by secondary systemic decompensation
Clinical presentation :• Hyperthermia• Tachycardia ( sinus or arrhythmias )• Heart failure• Jaundice ,Elevation in liver function test and fulminant hepatic failure• Diarrhea , nausea , vomiting , abdominal discomfort ,• Agitation , disorientation .
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• What precipitated this condition ???
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• What precipitates this condition ???
Surgery ,Infection ,Parturition ,Acute iodine exposure ,Radioactive iodine ,Medications including salicylates and pseudoephedrine
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How is it treated ??
1- supportive measures , including ABCs……etc. .2- decreasing thyroxin production by thyroid gland , HOW ??3- decreasing peripheral conversion of T4 to T3 , HOW ??4- address associated adrenergic and thermoregulatory changes5- treat all precipitating factors6- aggressively reverse any systemic decompensation and organdysfunction .
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Myxedema coma
• Systemic decompensation caused by severe hypothyroidism ,• Caused by ???
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Myxedema coma
• Systemic decompensation caused by severe hypothyroidism ,• Caused by ???✓ Non-adherence✓ MI , stroke✓ Heart failure✓ Cold exposure✓ Hypoglycemia✓ Acidosis✓ GI-bleeding ………….etc.
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manifestations
• Mental state changes ( including lethargy , stupor , psychosis m andcoma )
• Hypothermia ( temp less that 34.4 C )• Bradycardia• Hypoventilation and type 2 respiratory failure• Hypotension• Hyponatremia ( by which mechanism ???)• Hypoglycemia
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Management
1- supportive , including warming , ABCs….,and management of organdysfunction .2- TSH and free T4 , and CORTISOL should be check promptly, DON’TWAITE FOR TEST RESULTS , TREAT ASAP ,3-REPLACE CORTISOL IF DEFICIENCY IS SUSPECTED PRIOR TOREPLACEMENT OF THYROXIN , WHY???4-IV LEVOTHYROXINE
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