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Chapter 9 Primary Care in Gynecology. - Novak’s Gynecology page 199~230. Primary Care in Gynecology. Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health and is a key component of primary care.

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Chapter 9Primary Care in Gynecology

- Novak’s Gynecology page 199~230


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Primary Care in Gynecology

  • Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health and is a key component of primary care.

  • Although timely referral is important for complex and advanced disorders, the gynecologist initially may treat many conditions


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Primary Care in Gynecology

  • Respiratory Infections

    • Sinusitis

    • Otitis Media

    • Bronchitis

    • Pneumonia

  • Cardiovascular Disease

    • Hypertension

    • Cholesterol

  • Endocrinologic Disease

    • Diabetes Mellitus

    • Thyroid Disease


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Respiratory Infection

  • Sinusitis

  • Otitis Media

  • Bronchitis

  • Pneumonia


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Respiratory Infection Sinusitis

  • Etiology

    Infection : begin with a viral agent in the nose or nasopharynx that

    cause inflammation that blocks the draining ostia.

    • Viral agents : impede the sweeping motion of cilia in the sinus and,

      in combination with the edema from inflammation,

      lead to superinfection with bacteria

    • Bacterial agents: S.pyogenes, S.pneumoniae, H. influenzae,

      Staphylococcus aureus

      α-hemolytic streptococcus species

      * G(-) organism : usually limited to compromised hosts in

      intensive care units

      * chronic disease : polymicrobial with mixed infections consisting

      of aerobic and anaerobic organisms.


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Respiratory Infection Sinusitis

  • Factors to contributing the development of sinus disease

    : atmospheric pollutants, allergy, tobacco smoke, skeletal deformities,

    dental conditions, barotrauma from scuba diving, airline travel,

    neoplasm,

    # chronic sinusitis

    : systemic disease (connective tissue syndrome), malnutrition

  • Clinical finding

    1) maxillary toothache

    2) poor response to nasal decongestants

    3) abnormal transillumination

    4) a colored nasal discharge established by history

    5) a colored nasal discharge on examination

    - ≥4 : the likelihood of sinusitis↑

    - none : the likelihoodof sinusitis↓


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Respiratory Infection Sinusitis

  • Diagnosis

    • self-diagnosed : headache, dental pain, postnasal drainage,

      halitosis, dyspepsia

    • Imaging studies

      : not when initial episodes , but when persistent infections occur


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Respiratory Infection Sinusitis

  • Treatment

    • Broad antibiotic therapy

      : cover common aerobes and anaerobes

      patient with acute pain & purulent discharge

    • Systemic decongestants: pseudoephedrine

    • Topical decongestants

      : < 3days d/t rebound vasodilation and worsening of symptoms

    • Mucolytic agents (guaifenesin)

      : help thin sinus secretions and promote drainage

    • Antihistamins

      : avoided in acute sinusitis d/t drying effects may lead to thickened secretions and poor drainage of the sinuses.

    • Symptomatic therapies : facial hot packs and analgesics


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Respiratory Infection Sinusitis

  • Chronic sunusitis

    : from repeated infection with inadequate drainage

    • Sx: recurrent pain in the malar area or chronic postnasal drip

      associated with chronic cough and laryngitis with intermittent

      acute infection

    • Treatment

      - directed at the underlying etiology

      : allergy control or aggressive management of infections

      - Resistant cases : CT

      - Endoscopic surgery : polyp remove

    • Complication (- untreated sinus-)

      : orbital cellulitis leading to orbital abscess, subperiosteal abscess

      formation of the facial bones, cavernous sinus thrombosis, acute

      meningitis, brain & dural abscess (rare)


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Respiratory Infection Otitis Media

  • Serous otitis media

    • Cause

      : 2nd to a concurrent viral infection of the upper respiratory tract

    • Diagnosis

      : reveals fluid behind the tympanic membrane

    • Treatment

      : symptomatic Tx with antihistamines, decongestants, glucorticoids

      but, little data exist supporting use of these medications


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Respiratory Infection Otitis Media

  • Acute otitis media

    • Cause

      : bacterial infection - Streptococcus pneumoniae, H. influenzae

    • Sx .

      : acute purulent otorrhea, fever, hearing loss, leukocytosis

    • P. Ex

      : red, bulging or perforated membrane

    • Treatment

      : Broad-spectrum antibiotics

      - amoxicillin-clavulanic acid, cefuroxime, trimithoprim-sulfamethoxazole

      * antihistamines in treatment of otitis media is unclear


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Respiratory Infection Bronchitis

  • Acute bronchitis

    : inflammatory condition of the tracheobronchial tree

    • Causes

      - viral infection and occurring in winter

      : common cold viruses(rhinovirus and coronavirus), adenovirus,

      influenza virus, Mucoplasma pneumoniae (nonviral pathoen)

      - bacterial infections : less common and 2nd pathogens

    • Sx

      #coughning & sputum (prolonged in cigarette smokers) : m/c Sx


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Respiratory Infection Bronchitis

  • Diagnosis

    • P.Ex

      : Auscultation : coarse rhonchi (rales: not usually not auscultated )

      signs of consolidation and alveolar involvement : absent.

    • chest x-ray : to detect the presence of parenchymal disease

    • sputum culture

  • Treatment

    • symptomatic relief : uncomplictated cases

    • antibiotics : for patients who have chest radiographic findings

      consistent with pneumonia

    • atitussives (containing either dextromethorphan or codeine)

      : coughing (most aggravating symptom)

    • expectorants : efficacy –not been proved


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Respiratory Infection Bronchitis

  • Chronic bronchitis

    : defined as the presence of a productive cough with excessive

    secretions for 3months in a year for 2 consecutive years

    • Prevalence : estimated to be 10-20% of the adult population

    • Classified as a form of chronic obstructive disease (COPD)

    • Causes

      chronic infection and environmental pathogens found in dust

    • Sx

      cardinal manifestation : incessant cough,-usually in the morning ,

      with expectoration of sputum


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Sinusitis

Otitis media

bronchtis

Pneumonia


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Respiratory InfectionPneumonia

  • Definition

    : Inflammation of the distal lung that includes terminal airways, alveolar spaces and the interstitium

  • Causes

    : Viral , bacterial, aspiration pneumonia

    • Aspiration pneumonia

      cause : depressed awareness commonly associated with use of

      drugs, alcohol or anesthesia

    • viral pneumonia

      : multiple infection

      - influenza A or B, parainfluenza, respiratory syncytial virus

      : spread by aerosolization associated with coughing,

      sneezing, conversation

      * intubation time : short, requiring only 1~3days prior to the

      acute onset of fever, chills, headache, fatigue and myalgia


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Respiratory InfectionPneumonia

* pneumonia develops in only 1% of patients who have a viral syndrome

- mortality rates

: 30% in immunocompromised individuals and the elderly

* Staphylococcal pneumoniae (2nd bacterial pneumonia)

: arising from a previous viral infection, extremely lethal

* vaccination : influenza, pneumococcal pneumonia

amantadine : used to treat individual who have not been vaccinated

(in epidemics)

* Treatment : supportive care – antipyretics and fluids


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Respiratory InfectionPneumonia

  • Bacterial pneumonia

    • Classification : Nosocomial or community acquired

      - determine the prognosis and choice of antibiotic therapy

    • Risk factors

      : chronic cardiopulmonary diseases, alcoholism, DM, renal failure, malignancy, malnutrition

    • Signs and Symptoms

      : depending on the infecting organism and the patient’s immune status


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Respiratory InfectionPneumonia

  • Laboratory studies

    • Gram stain, sputum & blood culture

      * sputum collection : neutrophil > 25/LPF

      epithelial cell < 10/LPF

    • ELISA ( indirect serologic test)

      or direct fluorescent antibody staining of organisms in the sputum

      : Lesionella pneumoniae

    • cold agglutinin c appropriate clinical symptoms

      : Mycoplasma pneumoniae



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Respiratory InfectionPneumonia

  • Vaccination

    • Peumococcal vaccination

      - Indication

      : ≥ 65, heart, lung disease, alcoholism, renal failure, DM, HIV

      infection, cancer

      - repeat vaccination

      : recommended 5years after the 1st dose in high risk group

    • influenza vaccination

      - Indication

      : ≥50years, serious long term health problems like heart disease,

      lung disease, kidney disease, DM, immunosuppression 2nd to

      long-term steroid or cancer therapy, 3rd trimester of pregnancy

      during the flu season and anyone coming into close contact with

      people at risk of serious influenza (physicians, nurses, family

      members) * best time : October~mid November


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Respiratory InfectionPneumonia

  • poor prognosis factor

    : involvement >2 lobes, respiratory rate >30breaths/minute on arrival in the health care center, severe hypoxemia (<60mmHg breathing room air), hypoalbuminemia and septicemia

  • Complication : ARDS (mortality rate : 50~70%)


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Cardiovascular Disease

  • Hypertesion

  • Hyperlipidemia



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Cardiovascular DiseaseHypertension

  • Epidemiology

    -In U.S. : 15% of the population between the ages of 18 and 74 years

    • Incidence

      : increases with age and varies with race

      >50 years : female > male

      African Americans > Whites : twice

      Geographic variations : higher prevalence of hypertension and

      stroke in the southeastern United States regardless of race

  • Definition

    : blood pressure levels ≥140/90 when measured on two separate

    occasions


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Cardiovascular DiseaseHypertension

  • Primary or essential hypertension : >95%, cause unknown

  • Secondary hypertension : <5%

  • Diagnosis

    - Hx and P.Ex

    : presence of prior elevated readings, previous use of antihypertensive

    agents, a family history of death from cardiovascular disease prior to

    age 55, excessive alcohol and sodium use

    → lifestyle modification is increasingly important in the therapy of

    hypertension

    - Laboratory evaluations

    : rule out reversible causes of hypertension (secondary hypertension)

    UA, CBC, S/E, Cr, fasting glucose, total cholesterol, HDL cholesterol,

    EKG …


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Cardiovascular DiseaseHypertension

  • Measurement of Blood Pressure

    <Protocols for measurement>

    - patient should be allowed to rest for 5minutes in a seated position and the right arm used for measurements

    (for unknown reason, the right arm has higher readings)

    - cuff should be applied 20mm above the bend of the elbow and the arm

    positioned parallel to the floor

    - The cuff should be inflated to 30mmHg above the disappearance of

    the brachial pulse or 220 mmHg

    - the cuff should be deflated slowly at a rate ≤ 2mmHg/sec

    # cuff size : important

    cuff hypertension : small cuffs used for obese patients

    • Diastolic reading :

      - Phase IV : Korotkoff’s sounds (muffled sound)

      - Phase V : complete disappearance


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Cardiovascular DiseaseHypertension

Diagnosis and management are based on the classification of blood pressure readings



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Cardiovascular DiseaseHypertension

  • Treatment

    - General guidelines in assessing individuals for therapy



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Cardiovascular DiseaseHypertension

  • Choice of drugs

    • migraine headache : β-blockers or CCB

    • DM : ACEi

    • MI : β-blockers

    • African Americans: diuretics + CCB

  • Monitoring Therapy

    • Lifestyle modification (slightly elevated BP)

      - Interval : 1~2 week

    • With other disease (i.e.cardiovascular or renal)

      - lifestyle modification alone is successful

      : close monitoring - interval 3~6month

      - lifestyle modification is unsuccessful: medication


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Cardiovascular DiseaseHyperlipidemia

Cholesterol : esterized form with various proteins and glycerides that

chrarcterize the stage of metabolism

  • Important lipid particles in cholesterol metabolism

    • Chylomicrons

      : large lipoprotein particles - dietary triglycerides + cholesterol

      secreted in the intestinal lumen, absorbed in the lymph, and then

      passed into general circulation

      adhered to binding sites on the capillary wall and are metabolized

      for energy production. (in adipose tissue and skeletal muscle )

    • Lipoprotein Particle

      : consisted three major component

      - core : consists of nonpolar lipids (triglycerides & cholesterol ester)

      - surface coat of phospholipids : made of apoproteins & structural

      proteins

    • Apoprotein : attached to all lipoprotein particles have specific receptors and demarcate the stage of cholesterol metabolism


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Cardiovascular DiseaseHyperlipidemia

  • Lipoprotein classes

    :determined by the separation of lipids in an electrophoretic field

  • Prehepatic metabolites : CM and Remnants

  • Posthepatic metabolites : VLDL , IDL, LDL., HDL

  • Metabolism


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Cardiovascular DiseaseHyperlipidemia

  • Hyperlipoproteinemia

    • TG:choesterol > 5:1

      - predominant fractions are chylomicrons and VLDL

    • TG : cholesterol < 5:1

      - problem of VLDL and LDL fraction

  • Initial classification


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Cardiovascular DiseaseHyperlipidemia

  • Laboratory testing

    multiple environmental causes of variation in cholesterol measurements

    < major sources of variation >

    - diet, obesity, smoking, ethanol intake, effects of exercise

    - clinical conditions

    : hypothyroidism, DM, acute or recent MI, recent weight changes

    - other

    : fasting state, position while the sample is drawn, use and duration of

    venous occlusion . Anticoagulant and storage and shipping conditions


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Cardiovascular DiseaseHyperlipidemia

  • Intraperson variation

    • Age and sex

      < 50years, in women lower lipid values than men

      > 50 years, women lipid value increase d/t exogenous oral conjugated estrogens

    • Seasional variation

    • Diet and obesity

    • Alcohol and cigarette smoking

      : moderate (defined as approximately 2ounces of absolute alcohol/day)

      sustained alcohol intake is noted to HDL ↑ LDL ↓, TG ↑

      - this effect is negated with higher quantities

    • Smoking : LDL cholesterol and TG ↑, HDL cholesterol ↓

      (critical number : 15~20 / day)

    • Exercise : TG and LDL↓ HDL↑

    • Caffeine mixed effect on lipoprotein measurements, avoid in the 12hours prior to blood collection

  • * Blood sample : collected in the morning after a 12-hour fast


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Cardiovascular DiseaseHyperlipidemia

  • Disease States and Medication Effects

    - Diuretics, propranolol: TG↑, HDL cholesterol↓

    (esp. Diuretics : total cholesterol ↑)

    - DM : TG & LDL↑ HDL cholesterol↓

    - Pregnancy

    : total serum cholesterol ↓in 1st trimester, continuous increases of all

    fractions in 2nd~3rd trimester

    - Hypothyroidism : total cholesterol and LDL cholesterol ↑


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Cardiovascular DiseaseHyperlipidemia

  • Management

    • Once hyperlipidemia is confirmed on at least two separate occasions, 2nd causes should be diagnosed or excluded by taking a detailed medical and drug history, measuring Scr, fasting glucose level, performing thyroid, LFT

    • obese patients : diet and weight loss (1st)

    • Exercise and cigarette cessation



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Cardiovascular Disease levelHyperlipidemia


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Endocrinologic Disease levelDiabetes Mellitus

  • Definition

    : chronic disorder of altered carbohydrate, protein and fat metabolism from deficiency in the secretion or function of insulin

    : defined by either fasting hyperglycemia or elevated plasma glucose levels after an oral glucose tolerance test (OGTT)

  • Risk factors

    - age >45years

    - adiposity or obesity

    - a family history of diabets

    - Race and ethnicity

    - Hypertension (≥140/90)

    - HDL cholesterol ≤35mg/dL with or without a TG level ≥ 250mg/dL

    - History of gestational diabetes or delivery of baby >9 pound


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Endocrinologic Disease levelDiabetes Mellitus

  • Classification

    • Type 1 DM

      : The major metabolic disturbance of type 1 diabetes is the absence of insulin

      from destruction of β cells in the pancreas

    • Type 2 DM

      : heterogeneous form of disbetes that commonly occurs in older age groups

      (>40 years) and is more frequently noted to have familial tendency than type 1

      diabetes.

      # type 1 : an absence of insulin type 2 : resulting in insulin resistance


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Endocrinologic Disease levelDiabetes Mellitus

  • Diagnosis

    1. FBG (fasting blood glucose) ≥ 126mg/dL

    2. Random blood glucose ≥200mg/dL with classic signs and symptoms

    of diabetes

    (polydipsia, polyuria, polyphagia and weight loss)

    3. 2-hour OGTT (fasting sample, 60 and 120 minute samples) after a

    75g load of glucose

    → 2-hour OGTT should not be performed if the first two criteria are

    present.

    * Diagnostic criteria for imparied glucose intolerance (IGT)testing

    : 110mg/dL≤FRG<126mg/dL


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Endocrinologic Disease levelDiabetes Mellitus

  • Indication of DM testing

    - Age ≥45years (repeat at 3-year intervals)

    - Classic signs and symptoms of diabetes

    (i.e. polyuria, polydipsia, polyphagia and weight loss)

    - Ethnic groups at high risk

    (Pacific Islanders, Native Americans, Africal Americans, Hispanic Americans, Asian Americans)

    - Obesity

    - First-degree relative with diabetes

    - Gestational diabetes or birth of a baby over 9 pound

    - Hypertension (≥ 140/90)

    - HDL cholesterol levels≥35mg/dL or triglyceride level ≥250mg/dL

    - Impaired glucose tolerance based on previous testing


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Endocrinologic Disease levelDiabetes Mellitus


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Endocrinologic Disease levelDiabetes Mellitus

  • Treatment


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Endocrinologic Disease levelDiabetes Mellitus

  • Complication

    • Acute complication

      - Diabetic ketoacidosis (DKA)

      - Nonketotic hyperosmolar diabetic coma (NKHC)

      - Hypoglycemia

      - Lactoacidosis

    • Chronic complication

      - Macroangiopathy: accelerated atherosclerosis (CHD, MI, CVA…)

      - Microangiopathy : retinopathy, nephropathy, neuropathy

      - Other : infection, skin lesion


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Endocrinologic Disease levelThyroid Disease

  • Thyroid disorders are more common in women and some families, although the exact inheritance is unknown.

  • In geriatric populations, the incidence ≒5%

  • Thyroid function tests may be misleading in women receiving exogenous sources of estrogen because of altered binding characteristics (i.e. hormonal replacement therapy, pregnancy)

  • Hypothyroidism

  • Hyperthyoidism

  • Thyroid Nodules and cancer


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Endocrinologic Disease level Hypothyroidism

  • Incidence

    - overt hypothyroidism :2% of women, and at least an additional 5%

    develop subclinical hypothyroidism

    ( subclinical hypothyroidism : defined as an elevated serum TSH concentration with a normal serum free T4 level)


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Endocrinologic Disease level Hypothyroidism

  • Causes

    - Autoimmune thyroiditis (Hashimoto’s thyroiditis)

    - incidence increases with age

    - associated with other endocrine (e.g. type 1DM, primary ovarian failure, adrenal insufficiency and hypoparathyroidism) and nonendocrine disorders (e.g. vitiligo and pernicious anemia)

    - Familial predisposition

    ( specific genetics or environmental trigger is unknown)

    - Iatrogenic cause : after surgical removal or radioactive iodine therapy for hyperthyroidism of thyroid cancer

    - Secondary to pituitary or hypothalamic diseases from TSH or

    TRH deficiency


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Endocrinologic Disease level Hypothyroidism

  • Clinical Features

    - Fatigue, lethargy, cold intolerance, nightmares, dry skim, hair loss,

    constipation, periorbital carotene deposition (causing a yellow

    discoloration), carpal tunnel syndrome and weight gain(<5~10kg)

    menstrual dysfunction (menorrhagia or amenorrhea

    - Infertility (d/t anovulation)

    : exogenous thyroid hormone is not useful for women who are

    anovulatory and euthyroid

    - Neuropsychiatric symptoms

    : depression, irritability, impaired memory and dementia in the elderly

    - Not cause of premenstrual syndrome (PMS), but worsening PMS may

    be a subtle manifestation of hypothyroidism

    - Precocious or delayed puberty


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Endocrinologic Disease level Hypothyroidism

  • Diagnosis

    : confirmed with laboratory studies

    - Serum TSH↑, s-T4 or free T4 index ↓,

    - Autoimmune thyroiditis

    : confirmed by the presence of serum antithyroid peroxidase (antimicrosomal) antibodies

    * Central hypothyroidism

    : low or low-normal serum free T4 with either a low or inappropriately

    normal serum TSH concentration


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Endocrinologic Disease level Hypothyroidism

  • Treatment

    - L-thyroxine(T4), levothyroxine (Synthroid of Levothroid)

    : absorption may be poor when taken in combination with aluminum hydroxide (common in antacids), cholestyramine, ferrous sulfate or sucralfate because of binding or chelation

    - Normal daily dosage : 0.1~0.15mg

    (maintain TSH levels within the normal range)


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Endocrinologic Disease levelHyperthyroidism

  • Incidence

    : affects 2% of women during their lifetimes most often during their childbearing years

    * Graves’ disease represents the most common disorder

  • Causes

    - Graves’ disease

    - Transient thyrotoxicosis

    : result of unregulated grandular release of thyroid hormone in

    postparum (painless, silent or lymphocytic) thyroiditis and

    subacute (painful) thyroiditis

    - Other

    : hCG-secreting choriocarcinoma, TSH-secreting pituitary adenoma,

    and struma ovarii

    - Factitious ingestion or iatrogenic overprescribing


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Endocrinologic Disease levelHyperthyroidism

  • Clinical feature

    - Fatigue, diarrhea, heat intolerance, palpitations, dyspnea, nervousness,

    and weight loss.

    (In young patients : paradoxical weight gain from an increased appetite)

    - Vomiting in pregnant women- confused with hyperemesis gravidarum

    - P/Ex ) Tachycardia, lid lag, tremor, proximal m. weakness and warm, moist skin

    - Dramatic physical change : ophthalmologic and lid retraction , periorbital edema and proptosis, : 1/3 of women

    - In elderly adults : symptoms are often more subtle with presentations

    of unexplained weight loss, atrial fibrillation or new-onset angina

    pectoris

    - Menstrual abnormalities

    : regular menses, light flow, anovulatory menses and associated infertility


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Endocrinologic Disease levelHyperthyroidism

- Goiter : in younger women (m/c) c Graves’ disease

- Toxic nodular goiter is associated with nonhomogeneous glandular enlargement while in subacute thyroiditis the gland is tender, hard and enlarged

  • Diagnosis

    - Total and free T4 and T3 ↑

    (measured by radioimmune assay[RIA])

    - in thyrotoxicosis , S-TSH concentrations: undetectable

    - Radioiodine uptake scans

    : useful in the differential diagnosis of established hyperthyroidism

    * Thyroiditis and medication-induced thyrotoxicosis

    : glandular radioisotope concentration↓


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Endocrinologic Disease levelHyperthyroidism

  • Treatment

    • Antithyroid medication

      : PTU ( 50~300mg q6~8hours) or methimazole(10~30mg/day)

      : relapse rate : 50% over a lifetime

      - minor side effects : fever, rash or arthralgias

      - major toxicity (<1%) : hepatitis, vasculitis, agranulocytosis

    • Radioiodine

    • Surgical resection

    • Iodine-131

      : permanent cure of hyperthyroidism in 70~80%of patients

    • β-blocker (propranolol)

      : control of sympathomimetic symptoms (tachycardia), peripheral

      conversion of T4→T3


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Endocrinologic Disease levelHyperthyroidism

  • Thyroid storm

    :started immediately PTU, β-blockers, glucocorticoids

    and high-dose iodine preparations (SSKI or intravenous

    sodium sodium iodide)


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Endocrinologic Disease levelThyroid Nodule and Cancer

  • Incidence : common and found on P.Ex in ≥5% of patients

  • Character

    : most nodules- asymptomatic and benign

    - Malignant tendency

    : irradiation in childhood,

  • Diagnosis

    - TFT→ FNA→thyroid scan

    - Biopsy: provides a diagnosis in 95% of cases

  • Malignanacy

    - Papillary thyroid carcinoma (m/c)

    :75% of cases associated cervical lymph node metastasis, usually cured

    - Aplastic tumors

    : poor prognosis and progress rapidly despite therapy

  • Treatment

    : Radioiodine therapy or surgical ablation


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