Thyroid Disease

Question 1

What is Estrogen therapy’s effect on the thyroid?

Answer 1

Increases the thyroid binding hormone

Question 2

What drug can impact T4, T3, TSH, and TSAb lab test values?

Answer 2

BIOTIN

Question 3

19 y/o female 3 month Hx of sweating, tremor, palpitations, and weight loss of 10 lbs. Recent heat intolerance, proximal muscle weakness.

Family Hx HYPO thyroidism

Exam: 156/60, P-92
Tremor, stare, Thryroid normal size, non-tender

What is your differential?

Answer 3

Graves Disease (Hyperthyroidism)
Toxic multinodular goiter
Toxic adenoma
Subacute thyroiditis
Iatrogenic

Question 4

Which altered lab value could indicate and clinically help to definitively Dx Graves Dz?

What age group is it most common?

Answer 4

TSI and TSH-R –> Drives the thyroid to repeatedly causing the thyroid to create more T3 and T4

Widened pulse pressure

Age MC 20-50 y/o

Question 5

What are some clinical features of a hyperthyroidism case?

Answer 5

Hyperactivity
Heat intolerance, sweating, weight loss
Tremor, palpitations
Oligomenorrhea

Tachycardia, arrhythmias
Muscle weakness, lid lag, stare, goiter

Question 6

What is a significant risk factor which increases a hyperthyroid patient’s risk for Graves Ophthalmopathy?

Answer 6

SMOKING

Immunologic mediated

Everything turns green is the 1st sign of optic nerve traction

Question 7

What would the lab evaluation of a PT with Hyperthyroidism look?

Answer 7

TSH screen (LOW)
Free T4, Free T3 (HIGH)
          ~~remember T3 more metabolically active~~
Thyroid Receptor Antibody (POS (+))
Radioactive Iodine (HIGH)

Question 8

Which drug is the of choice for 1st Trimester pregnancy PTs who suffer from hyperthyroidism or for thyroid storm.

Answer 8

PTU propothiouracil

increased risk of Liver Toxicity

Question 9

What are some additional Anti-Thyroid drugs which you can Rx?

Answer 9

Tapazole
PTU
Organification of Iodide

Beta-blockers –> control adrenergic S/Sx

Question 10

What might a PT present as to your clinic if they suffered from Subacute Thyroiditis?

You decide to order labs; what labs would you order and what values would you expect to see?

Answer 10

Pxful or Pxless
VIRAL mediated most likely (recent fever)
Hyperthyroidism –> may lead to –> Hypothyroidism
Sweating, tremor, palpitations
Stare, 166/60, P: 88, tender

Elevated ESR
TSH, T4, and T3 varies
Low 131I uptake in beginning

Question 11

Fatigue
Weight Gain
Cold intolerance
Dry Skin
Swelling of the neck
No prior Hx of HTN
Edema 
Thyromegaly
Decreased DTRs
Bradycardia

Answer 11

Autoimmune Hypothyroidism (Hashimoto’s is Low)

MC in women –> lymphocytic infiltration of thyroid

Peroxidase antibody (+)

Question 12

What is the clinical presentation of Hashimoto’s?

Answer 12

Fatigue, weight gain
Cold intolerance
Dry skin
Thyromegaly
Decreased DTRs
Bradycardia
Edema

Question 13

What can cause Iodine excess?

Answer 13

Amiodarone

Kelp (seaweed)

Question 14

What lab values will present with a HYPO-thyroid patient?

Answer 14

TSH is HIGH

Free T4 and free T3 LOW

Question 15

What is the Tx for hypothyroidism?

Answer 15

L-thyroxine
~~Take on empty stomach
~~1/2 life is 7 DAYS

Follow TSH q two months

Question 16

What is the clinical picture for Subclinical Hypothyroidism?

Answer 16

Fatigue
Dry skin
Joint stiffness
TSH is slightly elevated
T3 and T4 are normal

(+) peroxidase antibody test

MC in DM1 WOMEN

Question 17

At what laboratory value will you decide to Tx a patient in respect to their TSH?

Answer 17

TSH over 10mU/L

Tx in less than 10 when…

1. Pregnant
2. Goiter
3. (+) thyroid antibodies (peroxidase)

Question 18

What is the 1/2 life of Amiodarone?

Why is this important?
What could it cause?

What would you use to counteract the effects of amiodarone?

Answer 18

100 days

High iodine can alter thyroid function and cause Thyroiditis (Hashimoto’s MC) or hypothryoidism
~~Inhibit T4 to T3 conversion
~~Block T3 receptor binding
~~Toxic to follicular cells

Tx with T4 (continue amiodarone)

Question 19

What psychiatric drug must you always check for a goiter?

Answer 19

Lithium

Question 20

Discuss the differences between Type 1 and Type 2 Amiodarone-induced Hyperthyroidism.

What would you Tx amiodarone induced hyperthyroidism with?

Answer 20

Type 1: HIGH T4 and T3
Pre-existing Graves, MNG (multi-nodular goiter)

Type 2: Destructive Thyroiditis
No new synthesis of T4 and T3

Methimazole –> TYPE 1
STEROIDS –> TYPE 2

Question 21

Post-partum mothers should always be checked for their thyroid and related PE for what condition?

Answer 21

Postpartum thyroiditis
~~Thyroid inflammation and follicular damage (Flood gates opened and T4 and T3 are released unregulated)
~~Transitions to HYPOthyroid phase

Question 22

What is the Tx for Postpartum Thyroiditis?

Answer 22

Hyperthyroid phase: beta blockers
Hypothyroid phase: Thyroid replacement
Annual TSH
EDUCATE –> Likely to happen w/ future pregnancies

Question 23

During normal pregnancy what thyroid based changes from baseline can you expect?

Answer 23

TBG elevated; increases bound T4 and T3

Hyperthyroidism MC is Graves during preg

hCG can upreg thyroid stimulation
~~Hyperemesis gravidarum –> Hyperthyroid

Question 24

What are 4 reasons T4 therapy for hypothyroid patients may need to be increased during pregnancy?

Answer 24

Increased T4 pool
High TBG
Placenta deiodinase (chews it up)
Reduced GI absorption (Fe in vitamins) must educate PTs to take medication at different time than prenatal vitamin

Question 25

If you note a nodule on the thyroid; what Tx / diagnostic protocol should you follow?

What PT demographic is most common to have a thyroid nodule?

Answer 25

Age 30-50 –> Women more likely than men

Check Thyroid Function Test
Cold Scan or FNA
U/S   (<1cm will determine not clinically sig.)
U/S Risks -->  Microcalcifications
                        Ratty borders

Question 26

What is sick euthyroid syndrome?

Answer 26

VERY ILL PATIENTS
Decreased T3 (May have decreased T4 if very ill)
Can occur with trauma
FEVER
Acute or chronic (NON-THYROIDAL ILLNESS)
No thyromegaly