Case Management: ThyroidJoey TabulaMayou Martin TampoKorina Ada Tanyu

General InformationMJA, 35/F, married, right-handed, Roman

Catholic, housewife from Infanta, Quezon

Chief complaint:

ABDOMINAL ENLARGEMENT

Patient Profile•No DM, HPN, BA•No vicesDIFFUSE TOXIC GOITER (2007)

anterior neck mass with associated palpitations,

dysphagia, dyspnea, tremors and heat intolerancePTU and Propanolol taken for ~ 6 months with

resolution of symptoms. Discontinued. Lost to follow-up.

6 mo PTC

RECURRENCE palpitationstremorsheat intolerance

Now with...Exertional dyspnea Gradual abdominal enlargement Progressive bipedal edema.

3 mo PTC 1 day PTC1 wk PTC2 wk PTC

ConsultedAdmitted in Lucena

and allegedly given IV antibiotics.

Discharged improved after 10 days

PTU and propanolol on fair compliance

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.

3 mo PTC 1 day PTC1 wk PTC4 wk PTC

6 mo PTC

Persistence of exertional dyspnea, abdominal enlargement, and bipedal edema.

Now with 2-pillow orthopnea and jaundice.

No consult

3 mo PTC 1 day PTC1 wk PTC4 wk PTC

6 mo PTC

•1 week prior to consult▫Increase in the severity of the exertional

dyspnea on mild activity, abdominal enlargement, and bipedal edema

▫Now with paroxysmal nocturnal dyspnea▫Consulted at a local hospital in Quezon▫“may tubig sa tiyan”▫Advised transfer to PGH for evaluation and

management

2 mo PTC 1 day PTC1 wk PTC2 wk PTC

6 mo PTC

Persistence of symptoms2 episodes of vomitingConsult at PGH

2 mo PTC 1 day PTC1 wk PTC2 wk PTC

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

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

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

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

Physical Examination at the ER• BP = 140/90, HR = 160s, RR = 24, T = 37.2• Awake, coherent, oriented• Icteric sclerae, 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

• Adynamic precordium, DHS, tachycardic, irregularly irregular rate

• Globular, NABS, soft, nontender, (+) fluid wave• bipedal pitting edema, anasarca, DTR ++

Differentials for HyperthyroidismDifferentials Points for Points againstGraves’ Disease With the above

mentioned SSx, especially the ophthalmopathy

Cannot be ruled out

Thyroiditis With the above mentioned SSx

Nontender goiter

Struma ovarii With the abovementioned SSx, abdominal enlargement

No masses palpable on PE

Drug induced hyperthyroidism

With the abovementioned SSx

No history of intake

Other ProblemsDifferential Points for Points againstCongestive Heart Failure prob sec to TTHD

NVE, ascites, crackles

Cannot be ruled out

Community-acquired pneumonia

Crackles, cough, fever, tachypnea

Cannot be ruled out

Working ImpressionDiffuse Toxic Goiter probabaly Graves’ Disease, in storm

Thyrotoxic Heart Disease in CHF FC III

r/o CAP-MRs/p IUD insertion (2000)

AF in

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

Course at the ER•Burch and Wartofsky Score (85)

▫Temperature – 5▫CNS – 0▫GI – 20▫Precipitant history - 10▫Cardiac (> 140) – 25▫CHF

Edema 5 Bibasal rales 10 AF 10

•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

Physical Exam at Med-ER• Awake, conscious, coherent• BP = 90/60, HR = 115, RR = 22, T = 37.2• Icteric sclerae, pink palpebral conjuctivae, (+)

anterior neck mass 10 x 10 cm• Equal chest expansion, no retractions, (+) bibasal

crackles• Adynamic precordium, 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

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

Albumin 22 low Alkaline phosphatase 94 AST 61 high ALT 42 Ca 1.86 low Mg 0.82Glucose 5.6 Crea 131 high Na 133 low K 3.2 low Cl 104PT 11.3/22.4/0.35/2.15APTT 35.8/52.8

U/A dark yellow hazy

1.015 pH 6 trace sug neg prot 0-1 RBC 1-3 WBC 0-1 hyaline casts 0-1 waxy cast occ epith cells neg crystals 1+ bact occ mt Bilirubin 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

7AM MICU DTG, instormWith TTHD in CHF FC III with AF in RVRWith TTLD

Decreased PTU 2 tabs q6Decreased Propanolol 1 tab TID defer if BP <90/60O2 prn

10 AM Day MHAPOD DTG Grave’s Disease in thyroid stormWith TTHD in CHF FC III with AF in RVRWith TTLD

Same

10:45AM Endo Maintainedr/o CAP

Increased PTU 4 tabs q4Increased SSKI 5 drops q4Increased Propanolol 40 mg q8

11 AM Day MHAPOD Started oral KCl 15 cc TID x 2 cyclesStarted NaCl tab 1 tab BID x 2 days

8:30 PM RIC Maintained Same

3/12/10 Endo Grave’s disease, storm resolvingWith TTHD in CHF FC III with AF in RVRWith TTLDAzotemia probably prerenal from poor intake and 3rd spacing losesAnemia multifactorial, IDA

d/c dexa and SSKIShifted PTU to Methimazole 20 mg q8Continued PropanololStarted Furosemide 40 mg IV q12 or tabDefer for BP <90/60 ideally bumetanideStarted oral KCl 10% 30 cc q8Resume digoxin once electrolyte corrected

3/13/105 PM

RIC Grave’s disease not in stormWith TTHD in CHF FC III with AF in RVRWith TTLD

Home meds:Furo 20 mg bidSpiro 25 mg poPropanolol 10 mg tidPTU 50 mg 2 tabs tidVit D +CaCO3 1 tab bidKalium durule 1 tab tid x 3 days

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

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)

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•Kalium durule TID x 3 d

Management of Thyroid Storm

Introduction•Thyrotoxicosis

▫Elevated thyroid hormone▫Most common causes:

Graves’ Disease (60-80%) Hyperthyroidism Thyroid storm (thyroid crisis)

Introduction•Hyperthyroidism ≠ Thyrotoxicosis

▫Conditions with increased thyroid hormone but normal thyroid function: Thyroiditis Thyrotoxicosis factitia

Signs and Symptoms• Represent a hypermetabolic state with increased

-adrenergic activity• 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

Signs and Symptoms•Other Signs:

▫Chest pain – often w/o cardiovascular disease

▫Psychosis▫Disorientation▫Hyperdefacation▫Edema

Signs and Symptoms•Other Symptoms

▫Diaphoresis▫Dehydration▫Fever▫Widened Pulse Pressure▫Thyromegaly

Graves = nontender, diffuse Thyroiditis = tender, diffuse Single nodule or MNG

▫Thyroid bruit

(Brief) Pathophysiology

Etiologies•Autoimmune•Drug-Induced•Infectious•Idiopathic•Iatrogenic•Malignant

Etiologies•Autoimmune

▫Graves▫Chronic thyroiditis (Hashimoto)▫Subacute thyroiditis (de Quervain)▫Postpartum thyroiditis

Etiologies•Infectious

▫Suppurative thyroiditis▫Postviral thyroiditis

•Idiopathic▫Toxic MNG

2nd most common cause of hyperthyroidism

Etiologies•Iatrogenic

▫Thyrotoxicosis factitia▫Surgery

•Malignant▫Toxic adenoma▫TSH – secreting pituitary tumor▫Struma ovarii

Etiologies• 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

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

Differential Diagnosis•Septic Shock•Heat Exhaustion/ Heat Stroke•Munchausen Syndrome•Withdrawal Syndromes•Toxicity

▫Anticholinergics (atropine)▫Selective Serotonin Reuptake Inhibitors

(fluoxetine)▫Sympathomimetics (dopamine)

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

Burch – Wartofsky Criteria

Thermoregulatory Dysfunction

Score Cardiovascular Dysfunction

Score

99-99.9 F (37.2-37.7 C) 5 Tachycardia

100-100.9 F (37.8-38.2 C) 10 99-109 BPM 5

101-101.9 F (38.3-38.8 C) 15 110-119 BPM 10

102-102.9 F (38.9-39.3 C) 20 120-129 BPM 15

103-103.9 F (39.4-39.9 C) 25 130-139 BPM 20

≥ 104 F (>40.0 C) 30 ≥ 140 BPM 25

Central Nervous System Score Congestive Heart Failure Score

Agitation 10 Pedal Edema 5

Delirium/Psychosis/ Lethargy 20 Bibasal Rales 10Seizure/Coma 30 Pulmonary Edema 15

GI – Hepatic Dysfunction Score Atrial fibrillation Present 10

Diarrhea, Nausea/Vomiting, Abdominal Pain

10 Precipitant History Present

10

Severe jaundice 20

Workup•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•Some lab abnormalities in thyroid storm

▫Hyperglycemia▫Hypercalcemia▫Hepatic function abnormalities▫Low serum cortisol▫Leukocytosis▫Hypokalemia (in HPP)

Imaging•CXR

▫May identify trigger for thyroid storm, ex. CHF or pneumonia

▫Thyroid scan Diffuse uptake = Graves Focal uptake = toxic adenoma

Other Diagnostics•12-L ECG

▫Sinus tachycardia (most common)▫AF (often in elderly)▫Complete heart block (rare)

Critical Care•Prompt institution of treatment

▫Hook to cardiac monitor Arrhythmia may convert to sinus only after

antithyroid tx▫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•Antithyroid Treatment

▫To prevent synthesis of new thyroid hormone:

▫Load 600 mg PTU then 200-300 mg q6 (PO, per NGT, per rectum) PTU prevents peripheral conversion of T4T3 Clinical effects may be seen after 1 hour

Critical Care•Antithyroid Treatment

▫To prevent release of preformed hormone:▫1 hour after loading PTU, give stable iodide

Wolff-Chaikoff vs. Jod-Basedow 5 drops SSKI q6 0.5 mg iopodate or iopanoic acid q12 Iodine allergy? Use lithium

Critical Care•Anti-adrenergic Treatment

▫Anti-adrenergic activity to control symptoms and heart rate High output heart failure

▫Propranolol 40-60 mg PO/NGT or 2 mg IV q4 High dose propranolol inhibits peripheral

conversion of T4T3

Critical Care•Corticosteroids

▫Dexamethasone 2 mg 6h Inhibits thyroid hormone synthesis Inhibits peripheral conversion of T4T3

▫Suspicion of Adrenal Insufficiency

Inpatient Care•Admit to ICU•Confirm diagnosis with labs•Clinical improvement a few hours after

therapy•Titrate medications to optimimize

antithyroid and antiadrenergic effects•Aggressively treat infection, underlying

precipitants

Inpatient Care•Admit to ICU•Confirm diagnosis with labs•Clinical improvement a few hours after

therapy•Titrate medications to optimimize

antithyroid and antiadrenergic effects▫May take 4-8 weeks after discharge

•Aggressively treat infection, underlying precipitants

Prognosis•Thyroid storm is usually fatal unless

treated▫Overall mortality 10-20%, some report 75%▫The precipitating factor is usually the

underlying COD•With early diagnosis and prompt

treatment, prognosis is good.

Patient Education•Stress the importance of medication

adherence.•Stress the importance of medication

adherence.•Explain the possible side effects of

treatment.▫Antithyroid – liver failure, agranulocytosis▫Anti-adrenergic – hypotension,

dermatologic▫Corticosteroids – cushingoid disease, DM

Medicolegalities• Because of variable presentation, thyroid storm

may be missed in patients who present obtunded or comatose.

• Apathetic thyrotoxicosis in the elderly▫Protracted duration of symptoms▫Weight loss▫Cardiovascular abnormalities (common)▫Ocular findings (less common)

• Consider thyrotoxicosis in patients with acute behavioural changes referred for psych evaluation.

Grave’s Disease

•60–80% of thyrotoxicosis.

•~2% of women but is 1/10 as frequent in men.

•rarely begins before adolescence and typically

occurs between 20 and 50 years of age, but it also occurs in the elderly.

Pathogenesis•ENVIRONMENTAL and GENETIC

▫ polymorphisms in HLA-DR, CTLA-4, and PTPN22 (a T cell regulatory gene.

• SMOKING is a minor risk factor for Graves' disease and a major risk factor for the development of ophthalmopathy.

• Sudden increases in iodine intake may precipitate Graves'

disease, and there is a 3x increase in the

occurrence of Graves' disease in the postpartum period.

• The hyperthyroidism of Graves' disease is caused by

TSI that are synthesized in the thyroid gland as well as in bone marrow and lymph nodes.

• Other thyroid autoimmune responses, similar to those in autoimmune hypothyroidism occur concurrently in patients with Graves' disease.

• In particular, TPO antibodies occur in up to 80% of cases and serve as a readily measurable marker of autoimmunity. In the long term, spontaneous autoimmune hypothyroidism may develop in up to 15% of Graves' patients.

•Cytokines appear to play a major role in thyroid-associated ophthalmopathy.

• Infiltration of the extraocular muscles by activated T cells; the release of cytokines such as IFN-, TNF, and IL-1 results in fibroblast activation and increased synthesis of glycosaminoglycans that trap water, thereby leading to characteristic muscle swelling.

• Late in the disease, there is IRREVERSIBLE FIBROSIS.

•TSH-R MAY BE A SHARED AUTOANTIGEN that is expressed in the orbit.

• INCREASED FAT is an additional cause of retrobulbar tissue expansion. The INCREASE IN INTRAORBITAL PRESSURE can lead to proptosis, diplopia, and optic neuropathy

Clinical Manifestations

•ophthalmopathy and dermopathy specific for Graves' disease

Opthalmopathy Grading0 = No signs or symptoms 1 = Only signs (lid retraction or lag), no

symptoms 2 = Soft tissue involvement (periorbital

edema) 3 = Proptosis (>22 mm) 4 = Extraocular muscle involvement

(diplopia) 5 = Corneal involvement 6 = Sight loss

In the elderly, features of thyrotoxicosis may be subtle or masked, and patients may

present mainly with fatigue and weight loss, a condition known as APATHETIC

THYROTOXICOSIS.

•UNEXPLAINED WEIGHT LOSS• WEIGHT GAIN OCCURS IN 5% •HYPERACTIVITY, NERVOUSNESS, AND IRRITABILITY• SENSE OF EASY FATIGABILITY • INSOMNIA AND IMPAIRED CONCENTRATION •FINE TREMOR •HYPERREFLEXIA, MUSCLE WASTING, PROXIMAL MYOPATHY

WITHOUT FASCICULATION• HYPOKALEMIC PERIODIC PARALYSIS (ASIAN MALES WITH

THYROTOXICOSIS)

•SINUS TACHYCARDIA, OFTEN ASSOCIATED WITH PALPITATIONS, OCCASIONALLY CAUSED BY SUPRAVENTRICULAR TACHYCARDIA

• HIGH CARDIAC OUTPUT PRODUCES A BOUNDING PULSE, WIDENED PULSE PRESSURE, AND AN AORTIC SYSTOLIC MURMUR

•ATRIAL FIBRILLATION IS MORE COMMON IN PATIENTS >50 YEARS

•WARM AND MOIST SKIN •SWEATING AND HEAT INTOLERANCE, • PALMAR ERYTHEMA, ONYCHOLYSIS• PRURITUS, URTICARIA, AND DIFFUSE ALOPECIA IN 40%• HAIR TEXTURE MAY BECOME FINE, AND A DIFFUSE ALOPECIA OCCURS IN UP TO

40% • GI TRANSIT TIME IS DECREASEDINCREASED STOOL FREQUENCY,

OFTEN WITH DIARRHEA AND OCCASIONALLY MILD STEATORRHEA• OLIGOMENORRHEA OR AMENORRHEA• IMPAIRED SEXUAL FUNCTION, RARELY, GYNECOMASTIA.

•OSTEOPENIA IN LONG-STANDING THYROTOXICOSIS• MILD HYPERCALCEMIA OCCURS IN UP TO 20% OF PATIENTS, BUT

HYPERCALCIURIA IS MORE COMMON SMALL INCREASE IN FRACTURE RATE IN PATIENTS WITH A PREVIOUS HISTORY OF THYROTOXICOSIS.

• GOITER 2X ITS NORMAL SIZE, FIRM, THRILL OR BRUIT• LID RETRACTION

•GRAVES' OPHTHALMOPATHY OR THYROID-ASSOCIATED OPHTHALMOPATHY▫occurs in the absence of Graves' disease in

10% of patients.

•Onset occurs within THE YEAR BEFORE OR AFTER the diagnosis of

thyrotoxicosis in 75% of patients.

THYROID DERMOPATHY occurs

in <5% of patients with Graves' disease

most frequent over the anterior and lateral aspects of the lower leg

(pretibial myxedema)THYROID ACROPACHY in

<1% of patients with Graves' disease

MANAGEMENT

Treatment of Graves’ Disease

Hegedus, L. 2009. Treatment of Graves’ Hyperthyroidism: Evidence-Based and Emerging Modalities. Endocrinol Metab Clin N Am 38: 355-371.

Treatment Choices•Antithyroid Drugs•Radioactive Iodine•Surgery

Antithyroid Drugs

PTU Methimazole

Carbimazole

Antithyroid Drug RegimensThe starting dose of antithyroid drugs can

be gradually reduced (TITRATION REGIMEN) as thyrotoxicosis improves.

High doses may be given combined with levothyroxine supplementation

(BLOCK-REPLACE REGIMEN) to avoid drug-induced hypothyroidism.

Other Drugs•Beta-adrenergic Antagonist Drugs•Glucocorticoids•Inorganic iodide•Iodine-containing compounds•Potassium perchlorate•Lithium carbonate•Novel Immunomodulatory agents

(rituximab)

Radioiodine Treatment•causes progressive destruction of thyroid

cells•can be used as initial treatment or for

relapses after a trial of antithyroid drugs•Small risk of thyrotoxic crisis, hence the

need for antithyroid drugs prior to radioiodine treatment▫Carbimazole or methimazole - stopped at

least 3 days before radioiodine administration

▫Propylthiouracil - has a prolonged radioprotective effect

Radioiodine Treatment• 131I dosage range between 185 MBq (5

mCi) to 555 MBq (15 mCi)•Tendency to relapse

▫thyroid ablation vs. euthyroidism•Safety precautions

▫Avoid contact with children and pregnant women

•Risk of hypothyroidism•Contraindicated in pregnancy and

breastfeeding mothers

Radioiodine Treatment•Severe ophthalmopathy requires caution

▫prednisone, 40 mg/d, at the time of radioiodine treatment, tapered over 2–3 months to prevent exacerbation of ophthalmopathy

Surgical•option for patients who relapse after

antithyroid drugs and prefer this treatment to radioiodine

•careful control of thyrotoxicosis with antithyroid drugs, followed by potassium iodide (3 drops SSKI orally TID needed prior to surgery

•complications▫bleeding, laryngeal edema,

hypoparathyroidism, and damage to the recurrent laryngeal nerves

•Thank you

3/11/102AM

DEMS DNTG in storm with CHF FC II-IIII with AF in RVRt/c CAP-MR

PTU 50 mg/tab 12 tabs now then 1 tab TID (2AM)Propanolol 40mg/tab now then40 mg tab ODDigoxin 0.25 mg IV nowFurosemide 40 mg IV (2:30AM)SSKI 5 drops q6, 1 hr post PTU (3:30AM)Dexamethasone 2 mg IV q6 (4:30AM)Hooked 4 lpm

4:50 AM

POD DTG in storm Thyrotoxic Heart Disease in CHF FC III with AF in RVRt/c CPC of the livers/p IUD insertion (2000)

PTU 50 mg/tab 2 tab q6Propanolol 10mg/tab TIDDigoxin 0.25 mg/tab ODSSKI 5 drops q6, 1 hr post PTU Dexamethasone 2 mg IV q6Paracetamol 500mg/tab for T 38.5O2 via NC at 2-4lpm, hook to CM

6 AM Gen Med DTG in storm Thyrotoxic Heart Disease in CHF FC III with AF in RVRt/c CPC of the livers/p IUD insertion (2000)

Increased PTU to 4 tabs q6Increased propanolol to 2 tabs TID

• 3/11/10 Alb 22 low alk phos 94 AST 61 high ALT 42 Ca 1.86 low Mg 0.82

• Gluc 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 dy h 1.015 6 trace sug neg prot 0-1 RBC 1-3 WBC 0-1

hyaline casts 0-1 waxy c occ epith cells neg crystals 1+ bact occ mt

Bilirubin 3+ trace ketone CBC 10.1 3.6 101 0.302 83.7 28.1 336 15.9 2010.7 0.15 0.14 0.01 03/13BUN 21.69 Crea 138 BCR 38.82 (prerenal azotemia)Mg 0.70 Na 137 K 2.7

• Decrease in edema• Decrease in resting dyspnea• Decrease in abdominal distension• No hyperdefecation• No agitation• No palpitations• With easy fatigability

• Awake afebrile not in distress• Stable VS no pallor AP, irreg irreg no murmur• Intact traubes (+) fluid wave, succusion splash, shifting dullness, bipedal edema

• A> Grave’s disease not in storm• t/c TTHD with CHF FC II in AF in CVR• t/c TTLD• Home meds

1. Furo 20 mg 1 tab bid 2. Spiro 25mg 1 tab od3. Propanolol 10 mg tid4. PTU 50 mg 2 tabs tid5. Vit d + CaCO3 1 tab bid6. Kalium durule tid x 3 d

Medication•PTU 600 mg loading dose then 200-300

mg q6h•SSKI 5 drops q6h 1hr after PTU •Propanolol 40-60 mg PO q4h or 2 mg IV

q4h•Dexamethasone 2 mg q6h