Case 9 SAP Flashcards
Effects of hypothyroidism in foetus and neonates
Severe mental retardation, dwarfism, iodine deficiency, lack of nerve myelination around birth
Symptoms of hypothyroidism in adults
decreased metabolic rate, mental and physical slowing, cold intolerance, weight gain, menorrhagia, depression symptoms, hypoventilation from diaphragm weakness, constipation from decreased GI motility, decreased cardiac output and stroke volume
Most common cause of hypothyroidism in developing countries
Iodine deficiency
Hashimoto’s thyroiditis
primary hypothyroidism. Autoimmune, thyroid peroxidase (TPO, more common) and thyroglobulin (less common) antibodies found. Low T4 and high TSH
Pituitary gland dysfunction effect on thyroid hormone levels
low TSH and low T4
What effect does thyroid gland ablation for hyperthyroidism have on thyroid hormone levels?
low T4 and high TSH
Drugs causing hypothyroidism (CLAPS)
amiodarone, carbamazepine, lithium, phenytoin, tyrosine kinase inhibitors (sunitinib)
Myxoedema coma
severe decompensated hypothyroidism, life threatening emergency, 70% fatalities.
What cause of hypothyroidism can pregnancy unmask?
subclinical autoimmune thyroid disease
How does oestrogen impact on T4 levels?
increases binding protein so decreases free T4
How does mother’s hypothyroidism affect the foetus?
impairs psychomotor development
What is given to keep maternal TSH in normal range?
levothyroxine
Tertiary hypothyroidism
decreased TRH release which leads to decreased TSH release and decreased T3 and T4. Causes include euthyroid-sick syndrome
Symptoms of hyperthyroidism
high metabolic rate, weight loss, tachycardia, tremor, nervousness, heat intolerance, goitre, reduced menses, anxiety symptoms
Describe graves’ disease
most common in females aged 30-40.
autoimmune condition in which antibodies attack the thyroid causing it to become overactive
Symptoms of graves’ disease
all hyperthyroidism symptoms plus increased lipolysis and protein catabolism leading to muscle weakness, increased GI motility, palpitations, increased cardiac contractility, hyperkinesia, increased bone turnover leading to fractures, and dermopathy
What else can cause hyperthyroidism?
Toxic multinodular goitre (Plummer’s disease) and thyroid adenoma
Describe thyroid storm and its causes
Severe decompensated (undiagnosed or poorly controlled) hyperthyroidism caused by trauma, pregnancy, infection, or surgery
Symptoms of thyroid storm
fever, agitation, delirium, congestive heart failure, loss of consciousness
Define domestic abuse
Any incident or pattern of incidents of controlling, coercive, or threatening behaviour, violence or abuse between those aged 16 or over who are or have been intimate partners or family members regardless of gender or sexuality
Types of domestic abuse
psychological, emotional, physical, sexual, and financial. Also includes ‘honour’ based violence, FGM, and forced marriage
Describe controlling behaviour
a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour
Describe coercive behaviour
an act or a pattern of acts of assault, threats, humiliation, and intimidation or other abuse that is used to harm, punish, or frighten their victim
Scale of domestic abuse
1 in 4 women, 1 in 6 men, 2 women killed every week, 1 man killed every 3 weeks, 30 women attempt suicide every week and 3 succeed. biggest prevalence in ages 16-19.
Effect of COVID on domestic abuse
Substantial increase due to COVID – reports that abuse has gotten worse, having to spend more time with the abusive partner, children witnessing more abuse, support line activity increases, ChildLine self-referrals increase
Risk factors for domestic abuse
pregnancy (foetal morbidity from violence more common than gestational diabetes and pre-eclampsia), disability (2x risk of DA), mental health problems (3x risk), teenaged, female gender, LGBTQ
Biopsychosocial impact of domestic abuse
Biological impact: cuts, scrapes, bruises, wounds, fractures, dislocations, lost teeth, STIs, unwanted pregnancies, non-specific symptoms (GI disorders, headaches, gynaecological problems x3, chronic pain, fainting, seizures), self-neglect, homicide.
Psychological: emotional distress, low self-esteem, depression x4, anxiety, suicidality x4, self-harm, PTSD (more common in males), alcohol and substance abuse, eating disorders, sleep disturbances.
Social: financial dependence on partner, impact on work, isolation from friends/family/support networks, homelessness, impact on ability to make decisions, impact on ability to parent, drink/drug behaviours, perpetrator always attending appointments to less chance to disclose
Impact of domestic abuse on health and health service
People experiencing DA use the health service more - tend to come into contact with GP before seeking help from authorities
Impact of DA on children
1 in 5 children have been exposed to DA, 62% of those in DA households are also directly harmed. Behavioural/emotional/mental health issues, neglect, physical abuse, truanting, bed wetting, premature sexual behaviour, drug and alcohol use
Define medically unexplained symptoms
physical symptoms persisting for more than several weeks for which adequate medical examination has not revealed a condition that adequately explains the symptoms
Common medically unexplained symptoms diagnoses
IBS, pelvic pain, non-cardiac chest pain, chronic headache, dizziness/vertigo, chronic fatigue, fibromyalgia
Medically unexplained symptoms stats
10-20% have multiple episodes
0.2% have severe with early onset (<30)
15-45% GP consultations have MUS
3-10% adults in primary care have persistent or recurrent
50-75% will have symptom decrease over 12 months
10-30% symptoms will worsen or increase
<4% with IBS have organic explanation
10% with fatigue have explanation
Impact of MUS
depression and anxiety more common in patients, can have significant impact on quality of life, similar rates of consultation as those with explanations
Theory of central sensitization
heightened perception of and distress from sensory input
Hyperalgesia
more pain than should be experienced from painful stimuli
Allodynia
pain from non-painful stimuli
Cause of hyperalgesia and allodynia
synaptic plasticity and loss of inhibition
Endocrine dysregulation theory
evidence of hypothalamic-endocrine dysfunction in many patients affecting the feedback loop that regulates stress responses. May be linked to the over production of cortisol which can result in chronic fatigue and pain
Immune system sensitization theory
chronic immune activation with production of cytokines that don’t switch off when the stressful stimulus is removes. Can give a feeling of illness.
Signal-filter model
uses the idea that we filter out signals in a manner very similar to that of pain which uses the gate theory. If our gates are broken, our perception of symptoms increases.
Management of MUS
acceptance of the person’s suffering and validation of their experience. Give explanation through models and analysis. Avoid opiates. Offer psychological support, exercise if appropriate, occupational support, patient support groups
Non-pharmacological treatments for schizophrenia
CBT, family therapy, arts therapy
Non-pharmacological treatments for dementia
CBT, psychotherapy, behavioural management therapy, memory training, music/dance therapy, support groups
Non-pharmacological treatments for depression
CBT, acupuncture, supplements, electroconvulsive therapy, repetitive transcranial magnetic stimulation
Non-pharmacological treatments for anxiety
limit caffeine, alcohol, nicotine, balanced diet, exercise, CBT, sleep
