Thyroid Disorders Summary - Treatment, Symptoms, and Causes

**Unit 3 \| Thyroid** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Elevated...

**Unit 3 \| Thyroid** - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Elevated temp 102-105F, profuse sweating, tachycardia, Afib, agitation, confusion, restlessness, coma, GI symptoms. - - - - - - - ○ Start with beta blocker therapy, then - - - Patient Education - Contact PCP if HR \120bpm - - - - - - - - - ○ neck discomfort or difficulty swallowing ○ Treatment of Hashimoto's Thyroiditis: levothyroxine - - - - ○ Postpartum thyroiditis ** Hashimoto's thyroiditis (chronic autoimmune thyroiditis)** ○ Most common cause of hypothyroidism in the U.S. ○ Subacute thyroiditis (usually viral) ○ Withdrawal of thyroid hormone therapy Iodine deficiency ○ Most common cause of thyroid disorders worldwide. Subclinical hypothyroidism (SCH) - Muscle cramps, tiredness, feeling colder, slowness of thinking, hoarseness, constipation ̶ - Hypothyroidism- Subjective data - ○ Most common presenting symptom is fatigue ○ Other classic symptoms: Cold intolerance, weight gain, Hoarseness, puffiness of the face and hands, Heavy and irregular menses, Dry skin, dry and brittle hair Bradycardia, OSA, dyspnea on exertion, hypoventilation Decreased DTRs, memory impairment Depression, constipation, muscle cramps, and paresthesia ○ Think LOW AND SLOW Objective data - - - - - - ○ Severe hypothyroidism leads to altered mental status, hypothermia, slowing function of internal organs ○ Labs- TSH, free T4, T4 index, antibodies if indicated - - - - - - Screening Recommendations - - - - - - - - ○ Advise monthly neck check if family history of thyroid cancer **Unit 4 \| Neurological** **Headache / Migraines** Headache - Headache Differentials - - - - - - - - - - - - - - - - - Visual, sensory, speech/language, motor, brainstem, retinal ○ C. At least 2 of the following 4: - - - - - ○ Mild to moderate attacks - NSAIDS, Acetaminophen, Aspirin Warn about rebound\*\*\* - Treximet® (sumatriptan + naproxen)\ ○ Do not give triptans to patients with vascular disease ○ Emotional stress (80%), Hormones in women (65 %), Not eating (57%), Weather (53%), Sleep disturbances (50%), Odors (44%), Neck pain (38%), Lights (38%), Alcohol (38%), Smoke (36%), Sleeping late (32%), Heat (30%), Food (27%), Exercise (22%), Sexual activity (5%) Migraine **WITHOUT** Aura Criteria ○ In Office Options → sumatriptan, ketorolac, diphenhydramine, dexamethasone Preventive Pharm Management → goal is to ↓ headache intensity and frequency ○ Beta blockers (propanolol), SSRIs / Tricyclic antidepressants, anticonvulsants (valproate) Non Pharm Management - Butterbur, feverfew, coenzyme, magnesium Medication Overuse Headaches ○ Common culprits: opioids, butalbital combos, caffeine combos, NSAIDs ○ Prevention - - - - - At least 2 of the following Both of Simple analgesics - NSAIDs, ASA + caffeine\ Caution about medication overuse headache Triptans may be effective for patients with co-existing migraine - **Cluster Headache** - - - - - \ ○ Acute Treatment Options 1\. Bilateral location\ 2. Pressing or tightening (non-pulsing quality) 3. Mild to moderate intensity\ 4. Not aggravated by physical activity\ the following\ No nausea or vomiting\ No photophobia or phonophobia ○ Treatment - - - - ○ Onset is acute and progressive\ Paralysis usually by 48 hours - - - - - - - - - - - - - - - **Seizures** - - - - - - Classification - Alzheimer's is 6th leading cause of death in US - - **Parkinson's Disease** Symptoms: tremor, rigidity, bradykinesia, postural disturbances The bacteria that cause meningitis are transmitted from person-to-person through droplets of respiratory or throat secretions from carriers. Close and prolonged contact -- such as kissing, sneezing or coughing on someone, or living in close quarters with an infected person, facilitates the spread of the disease. ○ Focal neural deficit ○ Eye pain or visual disturbance ○ Paresthesias or weakness of limbs - - - - - - - - - ○ Refer to pain management\ Monofilament Testing- quantitative measurement of simple sensation - Prevention of CV diseae - - - ○ Aspirin - preventative daily baby ASA for some populations - - - ○ T2DM: Metabolic disorder characterized by insulin resistance leading to hyperglycemia - - - - - - - - Statins, bile acid sequestrants, nicotonic acid, fibric acid, cholesterol absorption inhibitors\ ○ \*\*\* Combination therapy is useful when single-drug use and lifestyle changes do not achieve goals for lowering cholesterol - - Metformin (first line to improve glycemic control and reduce CV risk), semiglutide 2 inhibitors, GLP-IR agontists Total cholesterol below 200 mg/dL is optimal (high is above 240 mg/dL) LDL-C below 100 mg/dL is optimal (very high is above 190 mg/dL) HDL above 60 mg/dL is optimal (very low is below 40 mg/dL) Triglycerides below 150 mg/dL is optimal (very high is above 500 mg/dL) ○ - - - - - - - - - - - ○ Chest Pain Means More Than Pain in the Chest Pain, pressure, tightness, or discomfort in the chest, shoulders, arms, neck, back, upper abdomen, or jaw, as well as shortness of breath and fatigue should all be considered anginal equivalents. ○ High-Sensitivity Troponins Preferred - - - - - - - - - - b/p initial reading is ≥180/≥120 this is a hypertensive urgency/emergency Or - - ○ HTN with no identifiable cause (95% of cases) Women may be more likely to present with accompanying symptoms such as nausea and shortness of breath. → get an electrocardiogram as first line! "Noncardiac" should be used if heart disease is not suspected. B/P initial reading is ≥160/≥100 mmHg with known known target end-organ damage (eg, left ventricular hypertrophy \[LVH\], hypertensive retinopathy, ischemic cardiovascular disease) ○ Pathophysiology is an increase in peripheral arterial resistance as a result of increased cardiac output. - - - - - - - If true resistant hypertension and on max doses can add spironolactone (12.5 to 25mg to 50mg) Initial Treatment ○ CoMorbids of HFrEF\*, CAD → BB, ACE/ARB, Amlodipine (the dihydropyridines okay) \*\*Start with one of these and max the dose then add a second one of these if needed. - - ○ \ - - - - - - - - - - - - - ○ NOACs (novel oral anti-coauglaants) now - - ○ Anyone that requires CPR **Valvular Disease** - ○ Symptomatic murmur with the following: increase dyspnea on exertion, syncope, presyncope, chest pain Management → guideline directed therapy dependent on other risk factors (HTN, DM, HLD) ○ Most patients with LV systolic dysfunction and severe VHD should undergo intervention for the valve itself. **HEART FAILURE** - - ○ Diastolic Failure \~ Heart Failure with Preserved Ejection Fraction (HFpEF) result of the inability of the heart to relax and FILL with blood. (EF \ 45%- 50%) ○ Systolic Failure \~ Heart Failure with Reduced Ejection Fraction (HFrEF) result of the inability of the heart to EJECT blood. (EF≤ 40% ) Diagnostics - HFrEF is LVEF ≤ 40-45% ○ LVEF \ 40-45% and presence of HF symptoms = HFpEF Symptoms of HF ○ Dyspnea, DOE, reduction of exercise capacity, progressive weight gain, orthopnea, PND, LE edema, ascites, scrotal edema, wheezing or cough, confusion/ delirium, depression, fatigue, early satiety, N/V, abdominal discomfort Sorting through the Symptoms Left sided HF = lung sx\ ○ Right Sided Symptoms: edema, early satiety, increase abdominal size, ascites, RUQ abdominal pain, nausea, anorexia, abd bloating, constipation, hepatocongestion Right sided HF = body sx Diagnostic Testing - ○ Left Sided Symptoms: DOE, PND, orthopnea, dyspnea, sleep disturbances, fatigue, pleural effusions, wheezing, ronchi ○ ECHOCARDIOGRAM (TTE) It is the single most useful diagnostic test in the evaluation of heart failure. Transitioning from Hospital to Home - History, exam, testing, medication, therapy, education, consultations - Potassium supplements if needed for loop diuretics ○ Amiodarone possibly for ant-arrhythmic - - - - - - Treatment of HF Guideline Directed Medical Therapy (GDMT) ○ ACE-I or ARB or ARNI ○ intermittent claudication!!! i\. pain in legs associated with walking that is relieved with rest. ○ - - - i\. contraindicated with heart failure patients - - i. ii. iii. ○ Acute limb ischemia!!! i\. Less than 2 weeks -- requires urgent hospitalization ○ Unstable chronic limb ischemia i\. \> 2 weeks but non healing wounds which require emergent evaluation **Carotid Artery Disease** - - ○ Vital Signs i. ii. ○ Inspect, palpate, auscultate (for a bruit)\ Refer if\... patient having stroke/TIA symptoms in the clinic, imaging shows occlusion of carotid arteries **Aortic Aneurysm** Thoracic aortic aneurysm (ascending, arch and descending)\ ○ Risk factors: Genetic connective tissue disorders, hypertension i\. Marfan syndrome, Loeys Dietz syndrome, Vascular Ehlers Danlos Syndrome - i. ii. - - i. ii. iii. - iv. v. vi. vii. viii. - - - i. ii. - - Pathophysiology\ ○ Virchow's Triad -- local trauma to vessel wall, venous stasis, and hypercoagulability - - - ○ Anticoagulation -- initiate immediately with parenteral (heparin, LMWH, or fondaparinux) i\. Extended therapy with VKA (Warfarin) same day heparin is started until INR (2-3) - i\. (3-6 months versus indefinite) Surgical Treatment of DVT - - - - ○ Anticoagulation: for acute IV heparin first 5-10 days → warfarin (bridge) i\. DOACs: dabigatran, rivaroxaban, apixaban, edoxaban - - ○ Mild- Mod: exercise, compression, moisturize, weight loss, leg elevation ○ Severe: laser ablation, phlebectomy, foam sclerotherapy