Day 3 - Endo1 Thyroid

Question 1

Tx Thyroid storm

Answer 1

ICU (high mortality, need for frequent care), r/o infx w/ blood/urine cultx (empiric antibx if infx suspected), Hydrate aggressively (unless overt CHF), use glucose solutions, Replace multivitamins, digoxin (if one its 2 indications: CHF - improves contractility &/or Afib - slows down conduction; higher than normal dose may be required), Tylenol for fever (avoid ASA, which interfered w/ TBG, generating more free thyroid), Beta blockers (propanolol, esmolol - short-acting so given IV or constant infusion), Thionamides (PTU - also blocks T4 to T3 conversion on its own, Methimazole with Iopanoic acid), Iodine (block release of T4 from gland; dose at least 1 hr after thionamide to prevent creation of more thyroid hormone); +/- Glucorticoids (reduce T4 to T3, treat autoimmune if Graves’ disease)

Question 2

Considerations regarding Thyroid nodules (likelihood of malignancy)

Answer 2

-Incidence 4-5% adults - 1/10 cancer - Death rate: 1 in 1 mil -Higher chance of cancer if: child, elderly, history of external radiation, male, FH thyroid cancer - More likely malignant if: sonar/doppler shows irregular margins, intranodal vascular pattern, microcalcifications

Question 3

W/U Thyroid nodules

Answer 3

TSH, Free T4, Thyroid sonogram (assess size & check for other nodules); If hyperthyroidism, radionucleotide uptake scan - Hot nodule, tx hyperthyroidism -If cold nodule, concerning - FNA; If hypothyroidism, replace thyroid hormone & monitor for decrease in nodule size - if nodule not decrease in size, check FNA; If euthyroidism, FNA; If malignant on FNA, take nodule out; If benign on FNA, repeat thyroid sonogram q 6 mo. - 1 yr - If size increases, need to do FNA; If nondx on FNA, repeat FNA; If FNA negative, still 1% cancer, so surveillance or elective removal of nodule