Hyperthyroidism

Hyperthyroidism

by Hannah Aucoin

​Clinical Manifestations

• ​Anxiety

• ​emotional lability

• ​weakness

• ​tremor

• ​palpitations

• ​increased perspiration/ heat intolerance

• ​weight loss

• ​atrial fibrillation

• ​cardiopulmonary edema

​Causes of Hyperthryoidism

• ​Grave's Disease

• ​Subacute Thyroiditis

• ​Toxic Multinodular Goiter

• ​Toxic Adenoma

• ​Exogenous souce of thyroid hormone (ex. factitious hyperthyroidism)

Multiple Choice

A 30 year old woman presents to the ER with complaints of eye irritation and double vision. She also explains that recently she has lost weight, has heart palpitations, and also has felt her mood has been erratic. Currently her blood pressure is 145/70 mm Hg and her push is 111 bpm.. A physical exam is notable for bilateral eye redness and marked proptosis. What is the likely diagnosis in this patient?

• Hashimoto Thyroiditis

• Grave's Disease

• Toxic Multi-nodular Goiter

• Plummer's Disease

​Grave's Disease

• ​New-onset opthalmopathy

• ​Large non-nodular thyroid

• ​moerate to severe hyperthyroidism

• ​Thyrotropin receptor antibodies

• ​Radioactive iodine uptake scan: Diffuse increased uptake

• ​TSH is low and only T3 is high

​Exogenous thyroid hormone

• ​Levothyroxine is T4, so T3/T4 ratio is lower compared to Grave's Disease

• ​T4 also higher in patients who have nonthyroidal illness that prevents conversion of T4 to T3 (ex. Amiodarone)

​Treatment

• ​beta-blocker (atenolol 25 to 50mg/day)

• ​Antithyroid drugs

  • ​Assess CBC for neutropenia and elevated LFTs first

  • ​Methimazole is first line for Graves, longer MOA and once daily

  • ​PTU preferred in 1st trimester of pregnancy

• ​Radioiodine

• ​Surgery

Multiple Choice

A 39-year-old woman is seen in the office for the first time. She says she has had a sensation of fullness in her neck for the past 2 months. She has no medical problems and does not smoke or drink alcohol. She had a tubal ligation 4 years ago.

Her vital signs are a blood pressure of 115/76 mm Hg, a pulse of 78 beats/min and regular, a temperature of 97.8 °F (oral), and a body mass index (BMI) of 23.6. Her general physical examination is normal except for a palpable nodule in the right lobe of her thyroid gland.

What would be the most appropriate initial step in evaluating this palpable thyroid nodule?

• Order Thyroid Radionucleotide Uptake Scan

• Order TSH and thyroid ultrasound with survey of cervical lymph nodes

• Refer to endocrinologist for FNA

• Order Thyrotropin Receptor Antibodies

Multiple Choice

A 55-year-old woman is admitted to the hospital for hypotension and a hemoglobin level of 5.5 mg/dL due to an actively bleeding duodenal ulcer. She undergoes transfusion and endoscopic treatment and is observed in the intensive care unit on an intravenous infusion of a proton pump inhibitor.

On hospitalization day 2, her laboratory studies show a thyroid-stimulating hormone (TSH) level of 8.5 mIU/L (normal range, 0.4-4.2 mIU/L) and a free thyroxine level of 0.4 ng/dL (normal range, 0.8-2.4 ng/dL).

What is the most appropriate management of her thyroid dysfunction?

• Oral levothyroxine 50mcg daily

• IV levothyroxine 100mcg daily

• recheck thyroid studies as outpatient

• Check thyroid peroxidase antibodies