Case Management: Thyroid

1. Case Management: Thyroid Joey Tabula Mayou Martin Tampo Korina Ada Tanyu

2. General Information MJA, 35/F, married, right-handed, Roman Catholic, housewife from Infanta, Quezon Chief complaint: ABDOMINAL ENLARGEMENT

3. Patient Profile • No DM, HPN, BA • No vices DIFFUSE TOXIC GOITER (2007) anterior neck mass with associated palpitations, dysphagia, dyspnea, tremors and heat intolerance PTU and Propanolol taken for ~ 6 months with resolution of symptoms. Discontinued. Lost to follow-up.

4. 3 mo PTC 2 wk PTC 1 wk PTC 1 day PTC 6 mo PTC Consulted Admitted in Lucena and allegedly given IV antibiotics. Discharged improved after 10 days PTU and propanolol on fair compliance RECURRENCE palpitations tremors heat intolerance Now with... Exertionaldyspnea Gradual abdominal enlargement Progressive bipedal edema.

5. 3 mo PTC 4 wk PTC 1 wk PTC 1 day PTC 6 mo PTC Readmitted for dyspnea and abdominal enlargement. Given unrecalled meds probably diuretics which decreased the edema Discharged after 2 days with relief of symptoms.

6. 3 mo PTC 4 wk PTC 1 wk PTC 1 day PTC 6 mo PTC Persistence of exertionaldyspnea, abdominal enlargement, and bipedal edema. Now with 2-pillow orthopnea and jaundice. No consult

7. 2 mo PTC 2 wk PTC 1 wk PTC 1 day PTC 6 mo PTC • 1 week prior to consult • Increase in the severity of the exertionaldyspnea on mild activity, abdominal enlargement, and bipedal edema • Now with paroxysmal nocturnal dyspnea • Consulted at a local hospital in Quezon • “may tubigsatiyan” • Advised transfer to PGH for evaluation and management

8. 2 mo PTC 2 wk PTC 1 wk PTC 1 day PTC 6 mo PTC Persistence of symptoms 2 episodes of vomiting Consult at PGH

9. Review of systems • (+) weight loss ~50% • (-) loss of consciousness • (-) blurring of vision • (-) dizziness • (-) headache • (-) chest pain • (-) melena/hematochezia

10. Past and Family History • Past Medical History • As above • (-) PTB • No known allergies • Family Medical History • (+) hypertension – mother • (+) goiter – sister and brother • (-) DM, PTB, asthma, heart disease

11. Personal Social History • Housewife • With 4 children • No vices

12. OB-Gyne History • G5P5 (5005) • LMP: December 15, 2009 • PMP: November 2009 • Irregular, lasting for ½ month sometimes, consumes 6 cloths per day • IUD since 2000

13. Physical Examination at the ER • BP = 140/90, HR = 160s, RR = 24, T = 37.2 • Awake, coherent, oriented • Ictericsclerae, pink conjunctivae, (+) exophthalmos, neck vein engorgement, ANM 10 x 10 cm, non-tender, moves with deglutition • Equal chest expansion, subcostal and intercostal retractions, bibasal crackles, and rhonchi • Adynamicprecordium, DHS, tachycardic, irregularly irregular rate • Globular, NABS, soft, nontender, (+) fluid wave • bipedal pitting edema, anasarca, DTR ++

14. Differentials for Hyperthyroidism

15. Other Problems

16. Working Impression Diffuse Toxic Goiterprobabaly Graves’ Disease, in storm Thyrotoxic Heart Disease in CHF FC III r/o CAP-MR s/p IUD insertion (2000)

18. AF in

19. Course at the ER Diffuse nodular toxic goiter, in storm CHF FC II-III with AF in RVR, t/c CAP-MR

20. Course at the ER • Burch and Wartofsky Score (85) • Temperature – 5 • CNS – 0 • GI – 20 • Precipitant history - 10 • Cardiac (> 140) – 25 • CHF • Edema 5 • Bibasalrales 10 • AF 10

21. Labs done: CBC, RBS, Crea, Na, K, Ca, Mg, Albumin, ALT/AST, PT/PTT, urinalysis, 12 L ECG, xray (chest and abdomen) • Medications given • PTU 50 mg tab 12 tabs now then 1 tab TID • Propanolol 40 mg 1 tab now, then 40 mg tab • Digoxin 0.25 mg IV now • Furosemide 40 mg IV • SSKI 5 drops q6 h, 1 hour post PTU • Dexamethasone 2 mg IV q6 h • Referred to POD

22. Physical Exam at Med-ER • Awake, conscious, coherent • BP = 90/60, HR = 115, RR = 22, T = 37.2 • Ictericsclerae, pink palpebralconjuctivae, (+) anterior neck mass 10 x 10 cm • Equal chest expansion, no retractions, (+) bibasal crackles • Adynamicprecordium, distict heart sound, tachycardia, irregular rhythm, no murmur • Globular, normoactive bowel sounds, soft, (+) ascites, no tenderness • Full and equal pulses, pink nailbeds, (+) grade 2 bipedal edema

23. Course at the Med-ER • Assessment: DTG in storm, thyrotoxic heart disease, in CHF FC III, AF in VR, t/c CPC of the liver, s/p IUD insertion • Plan • NPO except medications • Keep on moderate high back rest • IVF: 1 liter D5NSS x 16 hours • Side drip: furosemide 100 mg in 100 cc PNSS in soluset at 4 cc/hr • Diagnostics: FT4, TSH, add FBS, lipid profile, holoabdominal UTZ, fecalysis • Tx: add paracetamol 500 mg tab 1 tab OD q4 prn for T ≥ 38.5

24. Albumin 22 low Alkaline phosphatase 94 AST 61 high ALT 42 Ca 1.86 low Mg 0.82 Glucose 5.6 Crea 131 high Na 133 low K 3.2 low Cl 104 PT 11.3/22.4/0.35/2.15 APTT 35.8/52.8 U/A dark yellow hazy 1.015 pH 6 trace sugnegprot 0-1 RBC 1-3 WBC 0-1 hyaline casts 0-1 waxy cast occepith cells neg crystals 1+ bactoccmtBilirubin 3+ trace ketone CBC WBC 10.1 3, RBC 6 , Hgb 101, Hct 0.302, MCV 83.7, MCH 28.1, MCHC336, RDW 15.9, PC 201, N 0.7, L 0.15, M 0.14, E 0.01, B 0 CXR: Cardiomegaly LV form

27. Laboratories Prior to Discharge • BUN 21.69, Crea 138, TB 560.56, DB 401.83, IB 158.73, Mg 0.70, Na 137, K 2.7

28. Discharge Diagnosis • Graves’ Disease, not in storm • Thyrotoxic Heart Disease in CHF FC III with Atrial Fibrillation in RVR • t/c Chronic-Passive Congestion of the Liver • s/p IUD insertion (2000)

29. Course in the Wards • Home medications • Furosemide 20 mg 1 tab bid • Spironolactone 25mg 1 tab od • Propanolol 10 mg tid • PTU 50 mg 2 tabs tid • Vitamin D + CaCO3 1 tab bid • Kaliumdurule TID x 3 d

30. Management of Thyroid Storm

31. Thyrotoxicosis • Elevated thyroid hormone • Most common causes: • Graves’ Disease (60-80%) • Hyperthyroidism • Thyroid storm (thyroid crisis) Introduction

32. Hyperthyroidism ≠ Thyrotoxicosis • Conditions with increased thyroid hormone but normal thyroid function: • Thyroiditis • Thyrotoxicosis factitia Introduction

33. Represent a hypermetabolic state with increased -adrenergic activity Signs and Symptoms • Hyperactivity, irritability, dysphoria • Heat intolerance and sweating • Palpitations • Fatigue and weakness • Weight loss with increased appetite • Diarrhea • Polyuria • Oligomenorrhea, loss of libido • Tachycardia, atrial fibrillation in the elderly • Tremor • Goiter • Warm, moist skin • Muscle weakness, proximal myopathy • Lid retraction or lag • Gynecomastia * in descending order of frequency

34. Other Signs: • Chest pain – often w/o cardiovascular disease • Psychosis • Disorientation • Hyperdefacation • Edema Signs and Symptoms

35. Other Symptoms • Diaphoresis • Dehydration • Fever • Widened Pulse Pressure • Thyromegaly • Graves = nontender, diffuse • Thyroiditis = tender, diffuse • Single nodule or MNG • Thyroid bruit Signs and Symptoms

36. (Brief) Pathophysiology

37. Autoimmune Drug-Induced Infectious Idiopathic Iatrogenic Malignant Etiologies

38. Autoimmune • Graves • Chronic thyroiditis (Hashimoto) • Subacutethyroiditis (de Quervain) • Postpartum thyroiditis Etiologies

39. Infectious • Suppurativethyroiditis • Postviralthyroiditis • Idiopathic • Toxic MNG • 2nd most common cause of hyperthyroidism Etiologies

40. Iatrogenic • Thyrotoxicosis factitia • Surgery • Malignant • Toxic adenoma • TSH – secreting pituitary tumor • Struma ovarii Etiologies

41. Thyroid storm (classically w/ underlying Graves or toxic MNG) can be triggered by: • Infection • General surgery • Cardiovascular events • Toxemia of pregnancy • DKA, HHS, insulin-induced hypoglycemia • Thyroidectomy • Non-adherence to antithyroid medication • RAI • Vigorous palpation of the thyroid gland Etiologies

42. Anxiety Panic Disorders Delirium Tremens Neuroleptic Malignant Syndrome CHF DM Differential Diagnosis

43. Septic Shock • Heat Exhaustion/ Heat Stroke • Munchausen Syndrome • Withdrawal Syndromes • Toxicity • Anticholinergics (atropine) • Selective Serotonin Reuptake Inhibitors (fluoxetine) • Sympathomimetics (dopamine) Differential Diagnosis

44. The Burch-Wartofsky Score • assess of the probability of thyrotoxicosis independently from the level of thyroid hormones • temperature, central nervous effect, hepatogastrointestinal, cardiovascular dysfunctin, and history • > 25 points thyrotoxicosis is possible • > 45 points, probable

45. Burch – Wartofsky Criteria

46. In thyroid storm, the diagnosis must be made on the basis of the clinical examination. • Total T4 not measured • variations in serum thyroid-binding proteins alter the ability to interpret results • TFT’s do not distinguish thyrotoxicosis from thyroid storm Workup

47. Some lab abnormalities in thyroid storm • Hyperglycemia • Hypercalcemia • Hepatic function abnormalities • Low serum cortisol • Leukocytosis • Hypokalemia (in HPP) Workup

48. CXR • May identify trigger for thyroid storm, ex. CHF or pneumonia • Thyroid scan • Diffuse uptake = Graves • Focal uptake = toxic adenoma Imaging

49. 12-L ECG • Sinus tachycardia (most common) • AF (often in elderly) • Complete heart block (rare) Other Diagnostics

50. Prompt institution of treatment • Hook to cardiac monitor • Arrhythmia may convert to sinus only after antithyroidtx • Intubate if profoundly altered sensorium • Aggressive fluid resuscitation (3-5L/d) • Profound GI and insensible losses • Thermoregulation with aggressive TSB and antipyretics • Avoid ASA  decreased protein binding increased fT3, fT4 Critical Care