Thyroid Abnormalities: Nodules, Cysts, and Disorders

Thyroid Abnormalities

• Functional abnormalities include hypersecretion (hyperthyroidism) and hyposecretion (hypothyroidism), affecting metabolism.
• Structural disorders involve goiter (common) and the presence of tumors/nodules.

Structural Thyroid Disorders

• Can manifest as asymptomatic and/or hyper/hypothyroid symptoms.
• Symptoms may include neck swelling, airway compression, and difficulty swallowing.

Thyroid Nodules

• Abnormal tissue overgrowths may be single or multiple
• They can be liquid or solid
• Classified as hot (hyper), warm, or cold
• Often asymptomatic
• Common in iodine deficiency, women, or advancing age
• May be hereditary disorders

Thyroid Cysts

• Nodules containing liquid, usually benign
• Can be asymptomatic, or cause difficulty in breathing, swallowing, or voice changes.
• Testing includes U/S, biopsy, and thyroid scan.
• Management includes draining but they may reoccur.
• Complex cysts or mixed echogenic nodules (liquid and solid components) can be cancerous.

Goiter

• Abnormal enlargement of the thyroid gland.
• May be asymptomatic, and occur in hyper/hypo/euthyroid states.
• Pathophysiology involves TSH receptor signaling which leads to gland hypertrophy.
• Risk factors include heredity, being female, age, and iodine deficiency.
• Causes include Graves, Hashimoto's, nodular goiter, thyroiditis, thyroid cancer, and radiation exposure.

Hyperthyroidism

• A clinical syndrome caused by excess production/release of thyroid hormone.
• Common causes include Graves' disease, subclinical hyperthyroidism, and thyroiditis.
• Subacute thyroiditis occurs post-viral illness and is tender, while silent thyroiditis is autoimmune and painless.
• Diagnostic testing will show increased free T4 and T3 while decreasing TSH.
• Can be treated with beta-blockers, thioamides (methimazole, propylthiouracil), radioiodine therapy, or thyroidectomy.
• Thioamide therapy requires baseline CBC and LFT checks, and PTU is preferred during the first trimester.
• Medical therapy is often the treatment of choice for patients under 20, pregnant women, and patients likely to go into remission
• Complications includes thyroid storm and untreated Graves' disease which can lead to Afib, CHF, angina, and osteoporosis.
• If untreated, patients may have a rare, life-threatening condition.
• It presents as elevated temperature, profuse sweating, tachycardia, Afib, agitation, confusion, restlessness, coma, and GI symptoms.
• Patients should review symptoms of hyperthyroidism, signs of thyroid storm, and monitor their pulse.
• Patients should be cautioned about serious effects of agranulocytosis if on thioamides.
• Patients should adhere to treatment
• Response to treatment takes 4-6 weeks
• Hypothyroidism can result from therapy

Autoimmune Disorders

• Sx: dry eyes, palpitations, tachycardia, angina, weight loss, anorexia, diarrhea, anxiety, heat intolerance, tremor, irritability
• Think "HIGH and DRY"
• Other sx: SOB, sleeplessness, menstrual irregularities, amenorrhea, goiter
• Older adults may present differently

Subclinical Hyperthyroidism

• Often a result of functioning thyroid nodules and multinodular goiter, common in elderly patients.
• Afib risk is related to the degree of TSH suppression.
• TFTs show suppressed TSH, normal serum T4 and T3 levels.

Thyroiditis

• Inflammation of the thyroid, may be subacute or painless, presenting with a tender thyroid gland and recent viral illness.
• Treated with beta-blockers, NSAIDs/ASA, or prednisone.
• Painless postpartum thyroiditis is treated with beta-blockers, but caution is advised with breastfeeding as it can concentrate in breast milk.
• May recur with subsequent pregnancies.
• Start with beta blocker therapy for toxic multinodular goiter, then radioiodine ablation is the treatment of choice.

Hypothyroidism

• A condition stemming from insufficient thyroid hormone synthesis to meet the body's needs, caused by inadequate hormone production/secretion.
• Bodily functions and metabolic processes slow. Untreated hypothyroidism can cause infertility, Hashimoto's encephalopathy, and myxedema coma. Diagnosis includes lab testing (elevated TSH, low thyroid hormone).
• Pathogenesis is unclear (genetic susceptibility, environmental factors)
• Symptoms of Hashimoto's thyroiditis: fatigue, weight gain, constipation, increased sensitivity to cold, dry skin, depression, muscle aches, reduced exercise tolerance, and irregular/heavy menses.
• Enlarged thyroid (goiter), enlarged painful thyroid or neck discomfort can be the cause
• Treatment: levothyroxine
• Autoimmune, smoking, thryoid injury r/t radiation, inadeuqate replacement therapy, drugs are the cause
• Management depends on age, TSH levels, and presence of sx
• Varies with age of onset, duration of illness, and severity of illness
• Early symptoms can be subtle and nonspecific

Congenital Hypothyroidism

• Developmental abnormalities
• Maternal antibodies to thyroid hormones
• Outcomes include developmental delays and mental retardation (cretinism)

Central Hypothyroidism

• Secondary hypothyroidism: pituitary gland fails to secrete adequate amounts of TSH.
• Tertiary hypothyroidism: inadequate secretion of TRH by the hypothalamus.

Iatrogenic Hypothyroidism

• Occurs after treatment with radioactive iodine or surgery, or with medications like amiodarone, lithium, interferon-a, dopamine, and thalidomide, accounting for 30 to 40% of cases.

Hashimoto's Thyroiditis

• Chronic autoimmune thyroiditis and the most common cause of hypothyroidism in the U.S.
• Subacute thyroiditis (usually viral)
• Can be caused by withdrawal of thyroid hormone therapy and iodine deficiency
• Most common cause of thyroid disorders worldwide and subclinical hypothyroidism (SCH)
• Elevated TSH presents with normal serum free thyroxine (T4)
• Most frequent reported symptoms:
  • Muscle cramps, tiredness, feeling colder, slowness of thinking, hoarseness, and constipation

Hypothyroidism Objective data

• Monitor BP, HR, respiratory rate, and weight
• Examine hair, eyebrows, tongue, face, nail, speech (slow, hoarseness)
• Begin with observation in the patient- overall appearance and energy level will be slowed
• They may appear Lethargic and expressionless
• Check Neurological exam, lungs and abdomen
• Neurological- may be hypotonic and or ataxic
• Possibly thyroid u/s and FNA

Hypothyroidism Management

• The most common presenting symptom is fatigue along with other classics symptoms, like cold interolance, weight gain, hoarseness, and heavy and irregular menses
• Dry skin, dry and brittle hair, bradycardia and hypoventilation may be presenting signs
• Think "LOW AND SLOW'
• Management includes taking Levothyroxine as a synthetic preparation of T4
• Prescriptions that do not allo substitutions and it should be increased every six weeks
• Referalls can be made to watch for patient signs of thyrotoxicitiy
• Specialiist consultation should be made for Hypothyroidism

Myxedema Coma

• A severe hypothyroidism with high mortality rate which requires immedaite medical attention
• Presentation: progressive lethargy, stupor, and coma or poorly responsive patient

Screening Recommendations

-Screen only if signs are present and follow TSH measurements in all women of childbearing age -Labs needed- TSH, free T4, thyrotropin receptor antibody, CBC, LFTs, ESR

Thyroid Cancer facts

• Classifications:
  • Differentiated (papillary and follicular) -Undifferentiated (medullary and anaplastic)
• Subjective Data:
  • A lump, or painless Module in the neck is a major symptom
• Diagnostic testing will show Tight/ full feeling in the neck, difficulty breathing/swallowing, Hoarseness, hemoptysis, and swollen lymph nodes
• Refer to endocrinology

Headache

• Headache and migraines are a unit 4 neurological disorder commonly seen

Headache characteristics

• Infectious disease -Inflammatory conditions -Structural disorder
• Metabolic/Others

Migraines

-Recurrent disorder with 4 phases

• Common trigger: pulsatile, one day duration, unilateral pain, Nausea or vomiting, and disabling

Migraines - with vs without Aura

Symptoms may present in visual, sensory, speech/language areas with At least 2 attacks fulfilling 4 characteristics

Managing Migraines

• Mild to moderate cases managed with
  • NSAIDS, Acetaminophen with caution for rebound effect -Add antiemetics if needed

Managing severe Migraines

• Imitrex
• Relpax
• Zomig
• Can combine triptans with NSAIDS

Migraine treatment

• Treximiet and do not over do triptan usage
• Emotional stress, hormones, lack of eating, weather Preventive Pharm-> reduces headaches Non pharm-training, biofeedback, acupuncture

Tension Headache

• Simple analgesics-NSAID
• caution -medication overuse headache
• Can trigger or worsen migraine

Cluster/Headache

• Neuromining to rule out any secondary symptoms
• Unilateral/ rest agitation, no physical activity will help
• Treatments include O2 and SubQ

Disorders:

• Bell's Palsy will affect the eye
• Can be seen through symptoms
• Refer if patient has stroke symptoms

Dizziness

• True-spinning or imbalance -Diaganose with TiTrATE and examine -Fall Risk Assessment

Seizures

-excessive electrical brain charge

• adults causes: meds, trauma, brain lesion
• Management: Home safety and symptom control

Meningitis

• Risk factures of Sicle cells, Skull fracture or neurosurgery
• Altered Mental state/ stiff neck

Other Disorders:

• Mult Scleoriss, MS
• Delirium, attention/ conciousness

Memory Loss

• Sign of memory loss that involve personality and language changes.

Paresthesia and Nueropathy

• Treat underlying causes, meds or pain magament

Caridovascular Health

• Diet, activity, control diabetes/ choesterol

Preventative Actions

• weight control, activity
• Manage palpitations/ syncope by taking synScope

Aches/PAD

• Artery Disease, Arterisl testings

Strokes can cause

• Blood clot in artery of cause decrease flow to the brain
• Recognize strocke symptoms

Vertigo/Dizzy

• Sense of spinning -Stroke

Aneurysms

-Aorta-genetic, heart

Deep Veins

• Thrombosis

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Overview of thyroid abnormalities, including functional (hyper/hypothyroidism) and structural disorders. Focus on thyroid nodules, cysts: formation, symptoms, diagnosis, and management. Includes liquid, solid, and mixed nodules.