c081thyroid present ( shuvro)

8/6/2019 c081thyroid Present ( Shuvro)

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Age: 45 yearsSex: Male

D/A: 15.07.08

D/D: 20.07.08

Admission problems :

1) Diarrhoea and vomiting- 3 days

2) Fever- 3 days

3) Loss of weight (despite normal appetite)- 6 to 76 to 7 months4) History of alternate bowel habit- > 1 year


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Past History :Past History :

1) No history of Diabetes, Tuberculosis, Hypertension,

Surgery etc.


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(on admission day)

O/ Ex : No pallor, jaundice, oedema, cyanosisTemp.- 38.4 CC

RR- 28 / min.Pulse- 120/min

BP- 100 / 40 mm of Hg

Palpit

ation during walking

Anxious , Heat intoleranceWarm hands and fine tremor

Muscle weakness with weight loss

Pruritus ( used comb to scratch body )

Lymph node enlargement (+)

Red eyes, Fatigue

Systemic examinations did not reveal

any significant abnormality


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Enlarged Thyroid

but no bruit

Pemberton`s

sign (-)ve

Plummer`s Nail


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.

Lid lag

(Von Graefe`s sign)

Lid retraction(Dalrymple`s sign)

Exophthalmos


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Infrequent Blinking(Stellwag`s sign)

Absence of wrinkling

of forehead

on sudden upward

Gazing

(Joffroy`s sign)

Impaired convergenceof the eyes

(Mobius` sign)


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Hct. - 30 %

TLC - 4900 /cumm

(N) - 63 %, (L) - 30%, (M) -7%

Total Platelet Count- 194,000/cumm

RBS - 6.4 mmol/l

R/S Culture - No Growth

Blood C/S - No Growth

Urine R/M/E - NAD

S/E - Mild Hypokalemia ( k+)


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X-Ray Chest X-Ray Neck


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ECG -

Sinus Tachycardia


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TSH 00.06 uIU/ml [ ] ( 0.40 4.00 )

FT-3 09.29 pmol/l [ ] ( 2.30 6.30 )

FT-4 67.80 pmol/l [ ] ( 10.3 24.5 )

Total Bilirubin - 04.70 umol/l [ ~ ] ( 0.01 19.0 )

Alka. Phosphatase - 79.40 u/l [ ~ ] ( 30.0 120 )

ALT - 51.20 u/l [ ] ( 0.01 41.0 )

Gamma GT - 84.70 u/l [ ] ( 9.00 40.0 )

T. Ca ++ - 02.16 mmol/l [ ~] ( 2.12 2.62 )


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Iodide Transport

Organification

Coupling

Storage

Secretion


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Thyrotoxicosissymtomatic hyperthyroxinemia

Hyperthyroidism

overactive tissue within

thyroid gland, resulting in

overproduction and thus an

excess of circulating freethyroid hormones

Thyrotoxic crisis ( Thyroid storm)

- rare condition where mortality is 10 %- rapid deterioration of hyperthyroidismwith hyperpyrexia, severe tachycardia,

extreme restlessness

- precipitating factor : stress, infection,

surgery in unprepared patient, radioiodine

therapy

Thyrotoxicosis Hyperthyroidism


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Clinical Thyrotoxicosis:- ELEVATED free thyroid hormone

levels and suppressed TSH level

Subclinical Thyrotoxicosis:- *NORMAL free thyroid hormone

levels and suppressed TSH level

Primary T-3 Toxicosis:- *NORMAL T-4 hormone but raised

T-3 hormone and suppressed TSH level

*Normal = Usually upper part of reference range


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High radioiodine uptake

Grave`s disease

Toxic nodular goiter

TSH-mediated thyrotoxicosis

Pituitary tumour

Pituitary resistance to

thyroid hormone

HCG-mediated thyrotoxicosis

Hydatidiform mole

Choriocarcinoma

Other HCG-secreting tumour

Thyroid carcinoma (very rare)

Low radioiodine uptake

Subacute thyroiditis

Hashitoxicosis

Drug induced

Iodide

Thyroid hormone

Struma ovarii

Factitious


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Low TSH Levels

Graves` disease

Toxic nodular goiter

subacute thyroiditis

Hashitoxicosis

Drug induced

Struma ovarii

HCG-mediated

Thyroid carcinoma ( very rare )

Hypothalamus

Pituitary

Thyroid

High TSH LevelsPituitary tumour

Pituitary resistance to Thyroid

hormone

Hypothalamus

Pituitary

Thyroid

1) Graves` disease (76%)

2) Toxic multinodular goitre (14%)

3) Toxic Nodular goitre (5%)


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Most Common :

-Weight loss despite normal or increased appetite- Palpitations, Dyspnoea on exertion

- Irritability, emotional lability

- Diffuse thyroid enlargement- Heat intolerance, sweating

- Hyperdefecation, Fatigue

- Lid retraction, Lid lag

- Grittiness, red eyes

- Palmar erythema- Tremor

In addition

Amenorrhoea, Impotance

Pruritus, Diplopia, Vitiligo

Atrial fibrillation,

Systolic hypertensionIncreased pulse pressure

Pretibial myxoedema,

Exophthalmos

Thyroid acropachy

Plummer`s Nails

Hyper-reflexia

Resolution of onycholysis

in the same patient 18 months later.


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Thyroid Function Tests

Radioactive Iodine Uptake

Technetium Scintigraphy

Others : CXR, ECG, FNAC

USG of Neck, MRI

S. Cholesterol, LFT

Blood Sugar


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Medical

Surgical

Radioactive Iodine


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My Colleagues

My Team Members


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High TSH Levels

Pituitary tumour

Pituitary resistance to thyroid

hormone


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Resolution of onycholysis

in the same patient 18 months later.

Onycholysis in a patient

with hyperthyroidism.

Plummer`s Nail


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Onycholysis in a patient with hyperthyroidism

Dr. Henry Plummer


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LID LAG


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Extra ocular muscles

in end stage


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Endocrine Disorders

Patients with thyrotoxicosis can present with intractable generalized pruritus. Itching may be due toincreased skin blood flow, which increases the skin temperature and decreases the itch threshold.

Patients with thyrotoxicosis and mucocutaneous candidiasis may present with localized itching in the

genital area. Myxedema causes severe itching due to dryness of skin.

Hyperthyroidism is the term for overactive tissue within the thyroid gland, resulting in overproduction and

thus an excess of circulating free thyroid hormones: thyroxine (T4), triiodothyronine (T3), or both. The term

is also often used more loosely to describe anysyndrome of excess thyroid hormone (more properlytermed hyperthyroxinemia), regardless of the source. Thyrotoxicosis is the term forsymptomatic

hyperthyroxinemia. Thyroid hormone is important at a cellular level, affecting nearly every type of tissue

in the body. It functions as a stimulus to metabolism, and is critical to normal function of the cell. In

excess it overstimulates, causing "speeding up" of various body systems, and thus symptoms: Fast heart

beat results in palpitations, a fast nervous system in tremorand anxiety symptoms, a fast digestive

system in weight loss and diarrhea. Lackof functioning thyroid tissue results in a symptomatic lack of

thyroid hormone, termed hypothyroidism


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In addition

1)Lid lag(when theperson is asked to slowly

look down, there is a delayin initiation of movement of

the upper lid downwards,such that the eyelid looks

like it is 'being left behind' )

2)Lid retraction(Theposition of the upper eyelid

when it is pulled back sothat the very top part of thecorneo-scleral junction is

visible. or

Upper lid margin at orabove superior limbus )


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c081thyroid present ( shuvro)

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