Block 3 Endocrine - Thyroid_Parathyroid PDF

Name Summary Etiology Age Hypothyroidism Decrease in production of thyroid hormones due to a number of reasons Autoimmune Infection Surgery/Radiation Signs Patient Pop Constitutional: - Cold intolerance - Fatigue - Weight gain Skin: - Myxedema - Dry skin - Alopecia Tests Treatment Primary hypothyroi...

Name Summary Etiology Age Hypothyroidism Decrease in production of thyroid hormones due to a number of reasons Autoimmune Infection Surgery/Radiation Signs Patient Pop Constitutional: - Cold intolerance - Fatigue - Weight gain Skin: - Myxedema - Dry skin - Alopecia Tests Treatment Primary hypothyroidism: - ↑ TSH - ↓ T3 or 4 Women Overall Levothyroxine Myxedema: Puffy, drooping bags under eyes (preorbital and or peripheral edema) Self Resolving Don't measure TSH/T4 in acutely ill patients Secondary hypothyroidism: - Normal/low TSH - ↓ T3 or 4 Reproductive: - Menorrhagia TSH: ↓ early disease; ↑ late disease Auto-immune destruction of thyroid Hashimoto's Thyroiditis Genetic Women MC cause of hypothyroidism in adults T4: ↑ early disease; ↓ late disease (+)TPO ± thyroglobulin antibodies Euthyroid Sick Syndrome Subclinical Hypothyroidism Myxedema Coma Low Thyroid hormones with normal TSH in acutely ill patients Will self resolve Illness causing lack of or decreased production of thyroid hormones Acutely Ill ↓ T4 T3 or 4: Normal ↑ TSH Asymptomatic findings Severe, extreme hypothyroidism Hyperthyroidism Increase in thyroid activity for a number of reasons Grave's Disease Autoimmune overproduction of Thyroid Stimulating Immunoglobulin (TSI) Send to hopsital ASAP MC cause of hyperthyroidism in adults Toxic Nodular Goiter - Ill Patient Constitutional: - Heat intolerance - Restlessness / tremor - Weight loss Skin: - Warm, flushed Eyes: - Exopthalmos Cardiovascular: - Afib - Wide pulse pressures - HTN Smoking women Neck: - Symmetric goiter Eyes: - Exophthalmos Younger women Nodule within thyroid is overactive Thyroidectomy - Surgical removal Older women Radioactive Iodine - Irradiate thyroid with I-131 - C/I in pregancy Refer to specialists to manage hyperthyroidism - Txs too in depth for primary care ↑ T3/T4 (+) Thyroid Receptor Ab - (TRAb) Thyroid Scan: - Single nodule or multiple "hot" nodules 5% association with thyroid cancer Hyperpyrexia Thyroid Storm Life-threatening hyperthyroidism Thyroiditis Usually self-limiting thyroid function derangement due to seocndary causes Precipitated by surgery, iodine therapy, physiological stress Constitutional: - Fever - Agitation/restless Skin: - Flushing - Diaphoresis Cardiovascular: - Afib - Cardiac failure STAT ICU admit - Beta Blockers - Antithyroid meds - Hydrocortisone - Iodine (prevents T4 conversion to T3) Acute: bacterial Thyroid Cancer Cancer. Of the Thyroid. - ↑ ESR Monitor - Thyroid level derangement - Beta-blocker Thyroid scan (symmetric - Levothyroxine if chronic diffuse, decreased uptake) hypothyroisism occurs Subacute: viral, post-partum Chronic: Post-subacute process like Hashimoto or post-partum Head or neck radiation, genetics (hx of medullary), nuclear radiation - Nonmobile, rapidly-growing, hard nodule - Vocal cord paralysis - ↑ calcitonin Younger women Thyroid scan: - Cold nodule - Solid lesion with microcalcifications - Thyroidectomy - Radioactive iodine ablasion (RIA) MOST COMMON TYPE: Papillary (usually peaceful and local) Medullary: Inherited. Can metastasize. Name Summary Etiology Signs Patient Pop Tests ↑ Calcium Parathyroid adenoma (80%) 1° Hyperparathyroidism Problem with PTH production at parathyroid level Gland hyperplasia Hypercalcemia sx Women Black 60YO ↑ PTH ↑ or normal Vit D Carcinoma ↓ or normal Phos ↑ PTH 2° Hyperparathyroidism Appropriate increase in PTH due to a secondary cause (non-parathyroid) Insufficient calcidiol so small intestine cannot convert to calcitriol Kidney disease pts ↓ or normal Ca Hypercalcemia sx Vit D deficiency ↑ urinary excretion of Ca Chronic stimulation causes hyperplasia and therefor too much PTH production Chronic stimulation resulting in hyperplasia which them causes autonomous PTH production Non-ParathyroidMediated Hypercalcemia Hypercalcemia from somewhere that isn't the parathyroid Malignancy 1° Hypoparathyroidism Acquired due to parathyroid loss or degradation 3° Hyperparathyroidism Hypercalcemia sx Chronic kidney disease ↑ PTH (ESRD) Chronic vit D deficiency ↓ or normal Ca Treatment Overall Parathyroidectomy (partial or complete) Encourage hydration Avoid HCTZ Rx: - Furosemide - Estrogen replacement - Cenacle (Sensipar) Refer to nephrology: - ↓ Phos levels - Replenish vitamins - Calcimemetics to stabilize Ca levels Refer to nephrology: - ↓ Phos levels - Replenish vitamins - Calcimemetics to stabilize Ca levels Largely the next step of secondary hyperparathyroidism ↓ or normal PTH Hypercalcemia sx w/ normal to low PTH ↑ Ca Secondary hypoparathyroidism Must test for etiology Post-surgical complication Auto-immune Copper/iron dz Post-infectious Post-surgical Wilson's dz/ hemachromatosis ↓ Calcium ↓ PTH ↓ or normal Vit D ↑ or normal Phos High dose Ca (target is lownormal serum Ca level) - Limited by nephrotox/lithiasis High dose Vit D Hungry Bone Syndrome: remaining parathyroid glands suppressed following resection leading to accelerated remineralization of bone 2° Hypoparathyroidism Pseudohypoparathyroi dism (maternal) Congenital maternal mutation causing end-organ resistant to PTH - Chronic hypocalcemia - Round face - Short stature Maternal GNAS1 gene mutation - Short 4th metacarpal bone - Obesity - SubQ calcifications - Developmental delay Family hx - Round face - Short stature Pseudohypoparathyroi Congenital paternal mutation causing Paternal GNAS1 gene mutation - Short 4th metacarpal bone - Obesity end-organ resistant to PTH dism (paternal) - SubQ calcifications - Developmental delay Non-Parathyroid Medicated Hypocalcemia Hypocalcemia from any non-PT source CKD Vitamin/mineral deficiency ↑ ↓← → ° ± Magnesium: ↑ Inhibits PTH ↓ Increases PTH; may be caused by PPIs, ETOH, aminoglycosides. Good History: - Osteoblastic mets - Vit D/Mg deficiency - Acute pancreatitis - Sepsis - Surgery PTH resistance causing chronic hypocalcemia Normal PTH Family hx No PTH resistant Normal Ca ↑ PTH ↓ Calcium Treat underlying causes Severe: - IV Calcium Name Summary Etiology Signs Patient Pop Tests Treatment Overall