Case Management: Thyroid
Joey Tabula
Mayou Martin Tampo
Korina Ada Tanyu
General Information
MJA, 35/F, married, right-handed, Roman
Catholic, housewife from Infanta, Quezon
Chief complaint:
ABDOMINAL
ENLARGEMENT
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.
6 mo
PTC
3 mo
PTC
2 wk
PTC
RECURRENCE
palpitations
tremors
heat intolerance
Now with...
Exertional dyspnea
Gradual abdominal
enlargement
Progressive bipedal
edema.
1 wk
PTC
1 day PTC
Consulted
Admitted in Lucena
and allegedly given
IV antibiotics.
Discharged
improved after 10
days
PTU and propanolol
on fair compliance
6 mo
PTC
3 mo
PTC
4 wk
PTC
1 wk
PTC
1 day 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 mo
PTC
3 mo
PTC
4 wk
PTC
1 wk
PTC
1 day PTC
Persistence of exertional dyspnea,
abdominal enlargement, and bipedal
edema.
Now with 2-pillow orthopnea and
jaundice.
No consult
6 mo
PTC
2 mo
PTC
2 wk
PTC
1 wk
PTC
1 day 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
6 mo
PTC
2 mo
PTC
2 wk
PTC
Persistence of symptoms
2 episodes of vomiting
Consult at PGH
1 wk
PTC
1 day 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, nontender, 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 Hyperthyroidism
Differentials
Points for
Points against
Graves’ 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 Problems
Differential
Points for
Points against
Congestive Heart Failure NVE, ascites, crackles
prob sec to TTHD
Cannot be ruled out
Community-acquired
pneumonia
Cannot be ruled out
Crackles, cough, fever,
tachypnea
Working Impression
Diffuse Toxic Goiter probabaly Graves’
Disease, in storm
Thyrotoxic Heart Disease in CHF FC III
r/o CAP-MR
s/p IUD insertion (2000)
AF in
Course at the ER
Diffuse 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 0.82
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 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, instorm
With TTHD in CHF FC III with
AF in RVR
With TTLD
10 AM
Day MHAPOD DTG Grave’s Disease in thyroid
storm
With TTHD in CHF FC III with
AF in RVR
With TTLD
10:45AM Endo
Maintained
r/o CAP
11 AM
Day MHAPOD
8:30 PM
RIC
Maintained
Decreased PTU 2 tabs q6
Decreased Propanolol 1 tab TID defer
if BP <90/60
O2 prn
Same
Increased PTU 4 tabs q4
Increased SSKI 5 drops q4
Increased Propanolol 40 mg q8
Started oral KCl 15 cc TID x 2 cycles
Started NaCl tab 1 tab BID x 2 days
Same
3/12/10 Endo
3/13/10 RIC
5 PM
Grave’s disease, storm resolving
With TTHD in CHF FC III with AF in
RVR
With TTLD
Azotemia probably prerenal from
poor intake and 3rd spacing loses
Anemia multifactorial, IDA
Grave’s disease not in storm
With TTHD in CHF FC III with AF in
RVR
With TTLD
d/c dexa and SSKI
Shifted PTU to Methimazole 20 mg q8
Continued Propanolol
Started Furosemide 40 mg IV q12 or tab
Defer for BP <90/60 ideally bumetanide
Started oral KCl 10% 30 cc q8
Resume digoxin once electrolyte corrected
Home meds:
Furo 20 mg bid
Spiro 25 mg po
Propanolol 10 mg tid
PTU 50 mg 2 tabs tid
Vit D +CaCO3 1 tab bid
Kalium 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
•
•
• Tachycardia, atrial
fibrillation in the elderly
Hyperactivity, irritability,
dysphoria
• Tremor
Heat intolerance and sweating
• Goiter
Palpitations
• Warm, moist skin
Fatigue and weakness
• Muscle weakness, proximal
Weight loss with increased
myopathy
appetite
• Lid retraction or lag
Diarrhea
Polyuria
• Gynecomastia
•
Oligomenorrhea, loss of libido
•
•
•
•
•
* 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
Thermoregulatory
Dysfunction
Score
Cardiovascular Dysfunction
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
10
Seizure/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
Burch – Wartofsky Criteria
Score
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 T4T3
 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 T4T3
Critical Care
• Corticosteroids
▫ Dexamethasone 2 mg 6h
 Inhibits thyroid hormone synthesis
 Inhibits peripheral conversion of T4T3
▫ 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
disease, and there is a
intake may precipitate Graves'
3x increase
of Graves' disease in the postpartum
in the occurrence
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.
TPO antibodies occur
in up to 80% of cases and serve as a readily
• In particular,
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 Grading
0 = 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 DECREASEDINCREASED 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 Regimens
The 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 
3/11/10 DEMS
2AM
DNTG in storm with CHF FC II-IIII
with AF in RVR
t/c CAP-MR
4:50
AM
POD
DTG in storm
Thyrotoxic Heart Disease in CHF FC
III with AF in RVR
t/c CPC of the liver
s/p IUD insertion (2000)
6 AM
Gen Med DTG in storm
Thyrotoxic Heart Disease in CHF FC
III with AF in RVR
t/c CPC of the liver
s/p IUD insertion (2000)
PTU 50 mg/tab 12 tabs now then 1 tab TID
(2AM)
Propanolol 40mg/tab now then40 mg tab
OD
Digoxin 0.25 mg IV now
Furosemide 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
PTU 50 mg/tab 2 tab q6
Propanolol 10mg/tab TID
Digoxin 0.25 mg/tab OD
SSKI 5 drops q6, 1 hr post PTU
Dexamethasone 2 mg IV q6
Paracetamol 500mg/tab for T 38.5
O2 via NC at 2-4lpm, hook to CM
Increased PTU to 4 tabs q6
Increased 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 15.9 201
0.7 0.15 0.14 0.01 0
3/13
BUN 21.69 Crea 138 BCR 38.82 (prerenal azotemia)
Mg 0.70 Na 137 K 2.7
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Decrease in edema
Decrease in resting dyspnea
Decrease in abdominal distension
No hyperdefecation
No agitation
No palpitations
With easy fatigability
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Awake afebrile not in distress
Stable VS no pallor AP, irreg irreg no murmur
Intact traubes (+) fluid wave, succusion splash, shifting dullness, bipedal edema
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A> Grave’s disease not in storm
t/c TTHD with CHF FC II in AF in CVR
t/c TTLD
Home meds
Furo 20 mg 1 tab bid
Spiro 25mg 1 tab od
Propanolol 10 mg tid
PTU 50 mg 2 tabs tid
Vit d + CaCO3 1 tab bid
Kalium durule tid x 3 d
1.
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Medication
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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