Hypothyroidism & HyperthyroidismA PowerPoint Presentation

prepared by:Group V BSN 3A

Hypothyroidism

I. INTRODUCTION

the disease state in humans and in vertebrates caused by insufficient production of thyroid hormone by the thyroid gland.

Early symptoms Poor muscle tone (muscle hypotonia) Fatigue Cold intolerance, increased sensitivity to cold Depression Muscle cramps and joint pain Carpal Tunnel Syndrome Goiter Thin, brittle fingernails Thin, brittle hair Paleness Osteoporosis Decreased sweating Dry, itchy skin Weight gain and water retention Bradycardia (low heart rate – less than sixty beats per

minute) Constipation

Signs and symptoms

Late symptomsLate symptomsSlow speech and a hoarse, breaking voice – Slow speech and a hoarse, breaking voice –

deepening of the voice can also be noticed deepening of the voice can also be noticed Dry puffy skin, especially on the face Dry puffy skin, especially on the face Thinning of the outer third of the eyebrows Thinning of the outer third of the eyebrows

(sign of Hertoghe) (sign of Hertoghe) Abnormal menstrual cycles Abnormal menstrual cycles Low basal body temperatureLow basal body temperature

Signs and symptoms

Signs and symptomsLess common symptomsLess common symptoms Impaired memoryImpaired memory Impaired cognitive function (brain fog) and Impaired cognitive function (brain fog) and

inattentiveness inattentiveness A slow heart rate with ECG changes including A slow heart rate with ECG changes including

low voltage signals. Diminished cardiac output low voltage signals. Diminished cardiac output and decreased contractility. and decreased contractility.

Reactive (or post-prandial) hypoglycemiaReactive (or post-prandial) hypoglycemia Sluggish reflexes Sluggish reflexes Hair loss Hair loss Anemia caused by impaired haemoglobin Anemia caused by impaired haemoglobin

synthesis (decreased EPO levels), impaired synthesis (decreased EPO levels), impaired intestinal iron and folate absorption or B12 intestinal iron and folate absorption or B12 deficiency from pernicious anemia deficiency from pernicious anemia

Difficulty swallowing Difficulty swallowing

CausesCauses

• About three percent of the general population is About three percent of the general population is hypothyroidic. Factors such as iodine deficiency or hypothyroidic. Factors such as iodine deficiency or exposure to Iodine-131 can increase that risk. There exposure to Iodine-131 can increase that risk. There are a number of causes for hypothyroidism. Iodine are a number of causes for hypothyroidism. Iodine deficiency is the most common cause of deficiency is the most common cause of hypothyroidism worldwide. In iodine-replete hypothyroidism worldwide. In iodine-replete individuals hypothyroidism is generally caused by individuals hypothyroidism is generally caused by Hashimoto's thyroiditis, or otherwise as a result of Hashimoto's thyroiditis, or otherwise as a result of either an absent thyroid gland or a deficiency in either an absent thyroid gland or a deficiency in stimulating hormones from the hypothalamus or stimulating hormones from the hypothalamus or pituitary.pituitary.

PrognosisPrognosis

Thyroid hormone replacement therapy generally Thyroid hormone replacement therapy generally maintains normal thyroid hormone levels unless maintains normal thyroid hormone levels unless treatment is interrupted or discontinued. treatment is interrupted or discontinued.

II. ANATOMY &

PHYSIOLOGY

Introduction to the Endocrine Introduction to the Endocrine SystemSystem

• The The endocrine systemendocrine system refers to the refers to the hormone system of the body. hormone system of the body.

• HormonesHormones are chemicals produced by are chemicals produced by living cells in very very small amounts. living cells in very very small amounts. They are transported around the body in They are transported around the body in the blood. Hormones regulate and co-the blood. Hormones regulate and co-ordinate different organs in the body.ordinate different organs in the body.

Hormones are classified Hormones are classified into two groups:into two groups:

• PeptidesPeptides 1.1. Made of proteins Made of proteins 2.2. Fast acting Fast acting 3.3. Short – lived Short – lived 4.4. E.g. Insulin and ADHE.g. Insulin and ADH

• SteroidsSteroids 1.1. Slow acting Slow acting 2.2. Long lasting Long lasting 3.3. Usually end in “one” Usually end in “one” 4.4. E.g. Testosterone and Progesterone.E.g. Testosterone and Progesterone.

The Structure of the The Structure of the Endocrine systemEndocrine system

The endocrine system is made up with a The endocrine system is made up with a series of glands located around the body. series of glands located around the body.

These glands include: These glands include: Pituitary Gland Pituitary Gland Thyroid Glands Thyroid Glands Parathyroid Glands Parathyroid Glands Thymus Thymus Pancreas Pancreas Adrenal Glands Adrenal Glands Gonads Gonads Each of these glands produces hormones, Each of these glands produces hormones,

which have a particular function in the body. which have a particular function in the body.

Pituitary GlandsPituitary Glands • The The Pituitary glandPituitary gland is located is located

in the hypothalamus (front of in the hypothalamus (front of the brain) and is the most the brain) and is the most important part of the endocrine important part of the endocrine system. The Pituitary gland has system. The Pituitary gland has two parts, the anterior and two parts, the anterior and posterior. posterior.

1.1. The The Anterior Anterior part produces two part produces two hormones, ADH and Oxytocin. hormones, ADH and Oxytocin.

2.2. The The Posterior part of the Posterior part of the PituitaryPituitary produces a number of produces a number of important hormones. These important hormones. These include FSH (Follicle include FSH (Follicle Stimulating Hormone), LH Stimulating Hormone), LH (Luteinizing Hormone), (Luteinizing Hormone), Prolactin and Growth Prolactin and Growth Hormones.Hormones.

Thyroid GlandsThyroid Glands

• The The thyroid glandsthyroid glands are found on the are found on the trachea. The main hormone produced is trachea. The main hormone produced is called thyroxine. This hormone controls called thyroxine. This hormone controls the growth and development of animals. the growth and development of animals. Iodine is required for its production. Iodine is required for its production.

• Lack of Lack of thyroxinethyroxine causes deformation causes deformation and retardation. The glands swell if not and retardation. The glands swell if not enough hormone is produced – this is enough hormone is produced – this is called goitre in humans.called goitre in humans.

Parathyroid GlandsParathyroid Glands These are located on either side of the thyroid. These are located on either side of the thyroid.

They produce two hormones: They produce two hormones: Parathormone and Parathormone and CalcitoninCalcitonin. These hormones control the level of . These hormones control the level of calcium, magnesium and phosphate in the body.calcium, magnesium and phosphate in the body.

ThymusThymus

A very small gland located on the neck. Has A very small gland located on the neck. Has some involvement in the production of some involvement in the production of lymphocytes, which are involved in immune lymphocytes, which are involved in immune response.response.

Adrenal GlandsAdrenal Glands

• The The adrenal glandsadrenal glands are found near the are found near the kidney. They produce over fifty different kidney. They produce over fifty different hormones which are vital for life. hormones which are vital for life.

GonadsGonads

• The gonads are the testes and ovaries. The gonads are the testes and ovaries. The hormones produced are involved in The hormones produced are involved in the reproductive systems of the animal. the reproductive systems of the animal. These include testosterone, oestrogen These include testosterone, oestrogen and progesterone. These hormones will and progesterone. These hormones will be looked at in more detail in Animal be looked at in more detail in Animal Reproduction.Reproduction.

Normal ThyroidNormal Thyroid

HypothyroidismHypothyroidism

HyperthyroidismHyperthyroidism

III.PATHOPHYSIOLOGY

IV. NURSING DIAGNOSIS

Imbalanced Nutrition: More than Body Requirements related to a slowed metabolic rate resulting in weight gain

Activity Intolerance related to weakness and apathy secondary to a decreased metabolic rate resulting in an increased heart rate and shortness of breath with activity

 Constipation related to decreased peristalsis secondary to slowed metabolic rate and activity intolerance, resulting in decreased frequency of stools and painful defecation

 Hypothermia related to slowed metabolic rate resulting in subnormal body temperature

V. NURSING INTERVENTIONS

MODIFYING ACTIVITYThe patient with hypothyroidism

experiences decreased energy and moderate to severe lethargy. As a result, the risk for complications from immobility increases.

A major role of the nurse is assisting with care and hygiene while encouraging the patient to participate in activities within established tolerance levels to prevent the complications of immobility.

MONITORING PHYSICAL STATUS

The nurse closely monitors the patients ital signs and cognitive level to detect the following:

Deterioration of physical and mental statusSigns and symptoms indicating that

treatment has resulted in the metabolic rate exceeding the ability of the cardiovascular and pulmonary systems to respond.

Continued limitations or complications of myxedema

PROMOTING PHYSICAL COMFORT

The patient often experiences chilling The patient often experiences chilling and extreme intolerance to cold, even if and extreme intolerance to cold, even if the room feels comfortable or hot to the room feels comfortable or hot to others. others.

Extra clothing and blankets are provided, Extra clothing and blankets are provided, and the patient is protected from dropsand the patient is protected from drops

Use of heating pads and electric blanket is Use of heating pads and electric blanket is avoided because of the risk of peripheral avoided because of the risk of peripheral vasodilation, further loss of body heat, and vasodilation, further loss of body heat, and vascular collapse. vascular collapse.

PROVIDING EMOTIONAL SUPPORT

The patient with moderate to severe hypothyroidism may experience severe emotionally actions to changes in appearance and body image and the frequent delay in diagnosis. As hypothyroidism is treated successfully and symptoms subside, the patient may experience depression and guilt as a result of the progression and severity of symptoms that occurred.The nurse informs the patient and family

that the symptoms and inability to recognize them are common and part of the disorder itself.

PROMOTING HOME AND COMMUNITY-BASED CARE

Because most hypothyroidism treatment takes place at home, the patient and family require information and instruction that will enable them to monitor the patients condition and response to therapy.»The nurse instructs the patient about the desired actions and side effects of meditations about how and when to take prescribe medications.

»The nurse provides written instructions and guidelines for the patient and family.

Cont’dThe patient with hypothyroidism and myxedema need considerable follow-up and healthcare.

Assistance the nurse reinforces the importance of continued thyroid hormone replacement and periodic follow-up and instructs the patient and family members about the signs of over medication and under medication.

V. MEDICATIONS

Hypothyroidism is traditionally treated with thyroid hormone replacement therapy (either synthetic or natural). Thyroid replacement therapy could include taking levothyroxine (T4), liothyronine (T3), or a combination product that contains both T4 and T3. All of these treatments work in the body like thyroxine, the human hormone that is normally produced by the thyroid gland, and subsequently converted to T3, the active hormone.

•LevothyroxineThe purpose of treatment is to replace the thyroid

hormone that is lacking. Levothyroxine is the most commonly used medication. Doctors will prescribe the lowest dose that effectively relieves symptoms and brings the TSH level to a normal range. If you have heart disease or you are older, your doctor may start with a very small dose.

Lifelong therapy is required unless you have a condition called transient viral thyroiditis.

You must continue taking your medication even when your symptoms go away. When starting your medication, your doctor may check your hormone levels every 2 - 3 months. After that, your thyroid hormone levels should be monitored at least every year.

Important things to remember when you are taking thyroid hormone are:

Do NOT stop taking the medication when you feel better. Continue taking the medication exactly as directed by your doctor.

If you change brands of thyroid medicine, let your doctor know. Your levels may need to be checked.

Some dietary changes can change the way your body absorbs the thryoid medicine. Talk with your doctor if you are eating a lot of soy products or a high-fiber diet.

Thryoid medicine works best on an empty stomach and when taken 1 hour before any other medications. Do NOT take thyroid hormone with calcium, iron, multivitamins, alumin hydroxide antacids, colestipol, or other medicines that bind bile acids, or fiber supplements.

MEDICAL MANAGEMENT(HYPOTHYROIDISM)

Treatment

Treating Overt Hypothyroidism. Patients with overt hypothyroidism, indicated by clear symptoms and blood tests that show high TSH (generally 10 mU/L and above) and low thyroxine (T4) levels, must have thyroid replacement therapy.

Treating Subclinical or Mild Hypothyroidism. Considerable debate exists about whether to treat patients with subclinical hypothyroidism (slightly higher than normal TSH levels, normal thyroxine levels, and no obvious symptoms). Some doctors opt for treatment and others opt for simply monitoring patients.

It is not clear if the benefits of treating subclinical hypothyroidism outweigh the risks and potential complications. Doctors who do not advocate treatment argue that thyroid levels can vary widely, and subclinical hypothyroidism may not persist. In such cases, overtreatment leading to hyperthyroidism is a real risk.

There is reasonable evidence and consensus to recommend treatment for subclinical hypothyroidism in the presence of other factors, including:High total or LDL cholesterol levelsBlood tests that show autoantibodies indicating a future risk for Hashimoto's thyroiditis or other forms of other autoimmune hypothyroidismBlood tests that show TSH levels greater than 10 mU/LGoiterPregnancyFemale infertility associated with subclinical hypothyroidism

Treatment is optional in patients with subclinical hypothyroidism who have no obvious symptoms and normal cholesterol levels. Some doctors feel that treating this group of patients will prevent progression to overt hypothyroidism and future heart disease, as well as increase a patient's sense of well-being. However, the evidence to support treatment of this patient group is not nearly as strong. Many doctors recommend against treatment and suggest that these patients should simply have lab tests every 6 - 12 months.

Suppressive Thyroid Therapy. Suppressive thyroid therapy involves taking levothyroxine in doses that are high enough to block the production of natural TSH but too low to cause hyperthyroid symptoms. It may be used for patients with large goiters or thyroid cancer.

Treatment of Special Cases

Treating the Elderly and Patients with Heart Disease. Thyroid dysfunction is common in elderly patients, with most having subclinical hypothyroidism. There is no evidence that this condition poses any great harm in this population, and most doctors recommend treating only high-risk patients. Elderly patients, particularly people with heart conditions, usually start with very low doses of thyroid replacement, since thyroid hormone may cause angina or even a heart attack. Patients who have heart disease must take lower-than-average maintenance doses. Doctors do not recommend treatment for subclinical hypothyroidism in most elderly patients with heart disease. Such patients should be closely monitored, however.

Treating Newborns and Infants with Hypothyroidism. Babies born with hypothyroidism (congenital hypothyroidism) should be treated with levothyroxine (T4) as soon as possible to prevent complications. Early treatment can help improve IQ and other developmental factors. However, even with early treatment, mild problems in mental functioning may last into adulthood. In general, children born with milder forms of hypothyroidism will fare better than those who have more severe forms.

Treatment During Pregnancy and for Postpartum Thyroiditis. Women who have hypothyroidism before becoming pregnant may need to increase their dose of levothyroxine during pregnancy. Women who are first diagnosed with overt hypothyroidism during pregnancy should be treated immediately, with quick acceleration to therapeutic levels. Although not well proven, doctors often recommend treating patients diagnosed with subclinical hypothyroidism while pregnant. There are no risks to the developing baby when the pregnant woman takes appropriate doses of thyroid hormones. The pregnant woman with hypothyroidism should be monitored regularly and doses adjusted as necessary. If postpartum thyroiditis develops after delivery, any thyroid medication should be reduced or temporarily stopped during this period.

Treatment of Hypothyroidism and Iodide Deficiency. People who are iodide deficient may be able to be treated for hypothyroidism simply by using iodized salt. In addition to iodized salt, seafood is a good source. Except for plants grown in iodine-rich soil, most other foods do not contain iodine. The current RDA for iodide is 150 micrograms for both men and women, with an upper limit of 1,100 micrograms to avoid thyroid injury.

Hyperthyroidism

I. INTRODUCTION

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

Thyroid hormone functions as a stimulus to metabolism and is critical to normal function of the cell. In excess, it both overstimulates metabolism and exacerbates the effect of the sympathetic nervous system, causing "speeding up" of various body systems and symptoms resembling an overdose of epinephrine (adrenaline). These include fast heart beat and symptoms of palpitations, nervous system tremor and anxiety symptoms, digestive system hypermotility (diarrhea), and weight loss.

Signs and symptomsweight loss (often accompanied by an weight loss (often accompanied by an

increased appetite)increased appetite) anxietyanxiety intolerance to heatintolerance to heat hair losshair loss muscle achesmuscle aches weaknessweakness fatiguefatigue hyperactivityhyperactivityIrritability Irritability ApathyApathy depressiondepression polyuria and sweating. polyuria and sweating.

Causes

The major causes in humans are:The major causes in humans are:Graves' disease (the most common etiology Graves' disease (the most common etiology

with 70-80%)with 70-80%) Toxic thyroid adenoma Toxic thyroid adenoma

Toxic multinodular goitre Toxic multinodular goitre

Prognosis

Hyperthyroidism is generally treatable and Hyperthyroidism is generally treatable and carries a good prognosis. Most patients lead carries a good prognosis. Most patients lead normal lives with proper treatment. Thyroid normal lives with proper treatment. Thyroid storm, however, can be life threatening and storm, however, can be life threatening and can lead to heart, liver, or kidney failure. can lead to heart, liver, or kidney failure.

II. ANATOMY &

PHYSIOLOGY

Introduction to the Endocrine Introduction to the Endocrine SystemSystem

• The The endocrine systemendocrine system refers to the refers to the hormone system of the body. hormone system of the body.

• HormonesHormones are chemicals produced by are chemicals produced by living cells in very very small amounts. living cells in very very small amounts. They are transported around the body in They are transported around the body in the blood. Hormones regulate and co-the blood. Hormones regulate and co-ordinate different organs in the body.ordinate different organs in the body.

Hormones are classified Hormones are classified into two groups:into two groups:

• PeptidesPeptides 1.1. Made of proteins Made of proteins 2.2. Fast acting Fast acting 3.3. Short – lived Short – lived 4.4. E.g. Insulin and ADHE.g. Insulin and ADH

• SteroidsSteroids 1.1. Slow acting Slow acting 2.2. Long lasting Long lasting 3.3. Usually end in “one” Usually end in “one” 4.4. E.g. Testosterone and Progesterone.E.g. Testosterone and Progesterone.

The Structure of the The Structure of the Endocrine systemEndocrine system

The endocrine system is made up with a The endocrine system is made up with a series of glands located around the body. series of glands located around the body.

These glands include: These glands include: Pituitary Gland Pituitary Gland Thyroid Glands Thyroid Glands Parathyroid Glands Parathyroid Glands Thymus Thymus Pancreas Pancreas Adrenal Glands Adrenal Glands Gonads Gonads Each of these glands produces hormones, Each of these glands produces hormones,

which have a particular function in the body. which have a particular function in the body.

Pituitary GlandsPituitary Glands • The The Pituitary glandPituitary gland is located is located

in the hypothalamus (front of in the hypothalamus (front of the brain) and is the most the brain) and is the most important part of the endocrine important part of the endocrine system. The Pituitary gland has system. The Pituitary gland has two parts, the anterior and two parts, the anterior and posterior. posterior.

1.1. The The Anterior Anterior part produces two part produces two hormones, ADH and Oxytocin. hormones, ADH and Oxytocin.

2.2. The The Posterior part of the Posterior part of the PituitaryPituitary produces a number of produces a number of important hormones. These important hormones. These include FSH (Follicle include FSH (Follicle Stimulating Hormone), LH Stimulating Hormone), LH (Luteinizing Hormone), (Luteinizing Hormone), Prolactin and Growth Prolactin and Growth Hormones.Hormones.

Thyroid GlandsThyroid Glands

• The The thyroid glandsthyroid glands are found on the are found on the trachea. The main hormone produced is trachea. The main hormone produced is called thyroxine. This hormone controls called thyroxine. This hormone controls the growth and development of animals. the growth and development of animals. Iodine is required for its production. Iodine is required for its production.

• Lack of Lack of thyroxinethyroxine causes deformation causes deformation and retardation. The glands swell if not and retardation. The glands swell if not enough hormone is produced – this is enough hormone is produced – this is called goitre in humans.called goitre in humans.

Parathyroid GlandsParathyroid Glands These are located on either side of the thyroid. These are located on either side of the thyroid.

They produce two hormones: They produce two hormones: Parathormone and Parathormone and CalcitoninCalcitonin. These hormones control the level of . These hormones control the level of calcium, magnesium and phosphate in the body.calcium, magnesium and phosphate in the body.

ThymusThymus

A very small gland located on the neck. Has A very small gland located on the neck. Has some involvement in the production of some involvement in the production of lymphocytes, which are involved in immune lymphocytes, which are involved in immune response.response.

Adrenal GlandsAdrenal Glands

• The The adrenal glandsadrenal glands are found near the are found near the kidney. They produce over fifty different kidney. They produce over fifty different hormones which are vital for life. hormones which are vital for life.

GonadsGonads

• The gonads are the testes and ovaries. The gonads are the testes and ovaries. The hormones produced are involved in The hormones produced are involved in the reproductive systems of the animal. the reproductive systems of the animal. These include testosterone, oestrogen These include testosterone, oestrogen and progesterone. These hormones will and progesterone. These hormones will be looked at in more detail in Animal be looked at in more detail in Animal Reproduction.Reproduction.

Normal ThyroidNormal Thyroid

HypothyroidismHypothyroidism

HyperthyroidismHyperthyroidism

III. PATHOPHYSIOLOGY

IV. NURSING DIAGNOSIS

Imbalanced Nutrition: Less than Body Requirements related to accelerated metabolic rate resulting in weight loss and decreased energy levels

Activity Intolerance related to exhaustion secondary to accelerated metabolic rate resulting in inability to perform activity without shortness of breath and significant increases in heart rate

Hyperthermia related to accelerated metabolic rate resulting in fever, diaphoresis, and reported heat intolerance

Impaired Social Interaction related to extreme agitation, hyperactivity, and mood swings resulting in inability to relate effectively with others

V. NURSING INTERVENTIONS

IMPROVING NUTRITIONAL STATUS

Rapid movement of food through the gastrointestinal tract may result to nutritional imbalance and further weight loss.Highly seasoned foods and stimulants

such as coffee, tea, cola, and alcohol are discouraged to reduce the area.

High calorie, high protein foods are encouraged.

ENHANCING COPING MEASURES

The patient needs reassurance that the emotional reactions being experience are a result of the disorder and that with effective treatment those symptoms will be controlled. Use a calm, unhurried approach with the

patient.Stressful experiences are minimized;

therefore, if hospitalized, the patient is not placed in a room with very ill or talkative patients.

The environment is kept quite and uncluttered.

The nurse encourages relaxing activities if they do not overestimate the patient.

IMPROVING SELF-STEEMThe patient is likely to experience changes in

appearance, appetite and weight. The nurse conveys and understanding of the

patients concern about these problems and assists the patient to develop effective coping strategies.

If changes in appearance are very disturbing to patient, mirrors maybe covered or removed.

The nurse reminds the family members and personnel to avoid bringing these changes to the patient’s attention.

The nurse explains to the patient and family that most of these changes are expected to disappear with effective treatment.

MAINTAINING BODY TEMPERATURE

The patient finds a normal room temperature too warm because of an exaggerated metabolic rate and increased heat production.The nurse maintains the environment

at a cool, comfortable temperature and changes bedding and clothing as needed.

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

The nurse closely monitors the patient with hyperthyroidism for signs and symptoms that maybe indicative of thyroid storm.

Anti-thyroid medications maybe prescribe to reduce thyroid hormone levels.

Propranolol and digitalis maybe prescribe to treat cardiac symptoms.

PROMOTING HOME AND COMMUNITY-BASED CARE

The nurse teaches the patient how and when to take prescribe medication, and provides instructions about the essential role of the medication and broader therapeutic plan.

The nurse provides a written plan for the patient to use at home

The nurse identifies adverse effects that should be reported if they occur.

The nurse also advises the patient to avoid stressful situations that may precipitate thyroid storm.

Cont’dThe nurse reinforces to the patient and

family the importance of long-term follow-up because of the risk for hypothyroidism after thyroidectomy or treatment with anti-thyroid medications or radioactive iodine.

The nurse also assesses the patient for changes indicating return to normal thyroid function and signs and symptoms of hyperthyroidism and hypothyroidism.

The nurse reminds the patients and family about the importance of health promotion activities and recommended health screening.

VI. MEDICAL MANAGEMENT

Radioiodine is considered the treatment of choice for hyperthyroidism, but in some situations, methimazole therapy is preferred, such as in cats with pre-existing renal insufficiency.Methimazole blocks thyroid hormone synthesis, and controls hyperthyroidism in more than 90% of cats that tolerate the drug. Unfavorable outcomes are usually due to side effects such as gastrointestinal (GI) upset, facial excoriation, thrombocytopenia, neutropenia, or liver enzyme elevations; warfarin-like coagulopathy or myasthenia gravis have been reported but are rare.

Surgical Procedure Surgery - this involves surgically removing the thyroid gland (thyroidectomy). It may be an option for patients who cannot tolerate anti-thyroid medications, or those who do not wish to receive radioactive iodine therapy. Patients will subsequently require thyroxine treatment to make sure their blood levels of thyroid hormones are adequate. The operative procedure to treat hyperthyroidism is known as a near total thyroidectomy

It is performed under general anesthesia.

The surgeon makes an incision in the skin lines across the front of the neck and carefully exposes the thyroid gland.

Precautions are taken to identify, isolate, and protect important structures in the area of the thyroid gland. Two are particularly important:

1. The laryngeal nerve, which is vital for the proper function of the larynx or voice box, is carefully identified and protected from trauma during this procedure.2. The four small parathyroid glands, which are embedded in thyroid tissue and produce a hormone necessary for maintenance of blood calcium levels, are also identified and preserved.

Most of the thyroid gland is removed.

The surgeon usually leaves about 3 to 8 grams, which is less the 0.3 ounces of thyroid tissue.

The procedure generally takes several hours. The incision usually heals well and is usually not even noticeable

Surgical CareThyroidectomy is no longer the recommended first-line therapy for hyperthyroid Graves disease. However, a recent retrospective cohort studyjavascript:showcontent('active','references'); showed that one-third of all patients electing surgery as definitive management did so without a specific indication, and the patient satisfaction with the decision for surgery as definitive management of Graves disease was high. Surgery is a safe alternative therapeutic option in patients who are noncompliant with or cannot tolerate antithyroid drugs, have moderate-to-severe ophthalmopathy, have large goiters, or refuse or cannot undergo radioiodine therapy.

Thyroidectomy may be appropriate in the presence of a thyroid nodule that is suggestive of carcinoma.In certain cases (eg, in pregnant patients with severe hyperthyroidism), thyroidectomy may be indicated because radioactive iodine and antithyroid medications may be contraindicated.It generally is reserved for patients with large goiters with or without compressive symptoms.It also may be indicated in patients who refuse radioiodine as definitive therapy or in those in whom the use of antithyroid drugs and/or radioiodine does not control hyperthyroidism.

Surgery provides rapid treatment of Graves disease and permanent cure of hyperthyroidism in most patients, and it has "negligible mortality and acceptable morbidity" by experienced surgeons.

OphthalmopathyNear-total thyroidectomy has little, if any, effect on the course of ophthalmopathy.

If ophthalmopathy is severe but inactive, orbital decompression may be performed. Reducing proptosis and decompressing the optic nerve can be achieved by transantral orbital decompression.The major adverse effect is postoperative diplopia, which may necessitate a second surgery on the extraocular muscles to correct the problem.

Rehabilitative (extraocular muscle or eyelid) surgery is often needed. Eyelid surgery (eg, severance of the Müller muscle, scleral or palatal graft insertion) can be performed to improve exposure keratitis.

VII. MEDICATIONS

Hyperthyroidism can be treated using medicine, radiation, or surgery. Many factors, such as the

person's age and the severity and type of hyperthyroidism, are important in determining which treatment is best. The two main types of

medicines used to treat hyperthyroidism are antithyroid drugs and beta-blockers.

Anti-thyroid DrugsAntithyroid drugs, such as methimazole (MMI

or Tapazole) and propylthiouracil (PTU), work by decreasing the production of thyroid hormone. Both are very effective, but methimazole is generally preferred because of a rare risk of serious side effects with PTU. The illustration shows that some hormone is made, but the thyroid becomes much less efficient. When taken faithfully, these drugs are usually very effective in controlling hyperthyroidism within a few weeks.

Cont’dFor pregnant women, PTU is the

preferred drug during the first trimester. After the first trimester, methimazole is preferred.

For patients with sustained forms of hyperthyroidism,

such as Graves' disease or toxic nodular goiter, anti-thyroid medications are often used. The goal with this form of drug therapy is to prevent the thyroid from producing hormones.

Very rarely, patients treated with these medications can develop liver inflammation or a deficiency of white blood cells therefore, patients taking antithyroid drugs should be aware that they must stop their medication and call their doctor promptly if they develop yellowing of the skin, a high fever, or severe sore throat. The main shortcoming of antithyroid drugs is that the underlying hyperthyroidism often comes back after they are discontinued. For this reason, many patients with hyperthyroidism are advised to consider a treatment that permanently prevents the thyroid gland from producing too much thyroid hormone.

Cont’d

SIDE EFFECTS:

Rash itching or fever (but these are uncommon)

Methimazole (MMI) MMI is usually preferred over PTU

because it reverses hyperthyroidism more quickly and has fewer side effects. MMI requires an average of 6 weeks to lower T4 levels to normal and is often given before radioactive iodine treatment. MMI can be taken once per day.

Propylthiouracil (PTU) 

PTU blocks the conversion of T4 to T3 in non-thyroid tissue, but it does not reverse hyperthyroidism as rapidly as MMI. PTU must be taken two to three times per the day.

Antithyroid drugs during pregnancy

PTU used to be the drug of choice during pregnancy because it is thought to have a lower risk of causing birth defects. But experts now recommend that PTU be given during the first trimester only. This is because there have been rare cases of liver damage in people taking PTU. After the first trimester, women should switch to methimazole for the rest of the pregnancy.

Beta-blockers Beta-blockers, such as atenolol, are often

started as soon as the diagnosis of hyperthyroidism is made. While beta-blockers do not reduce thyroid hormone production, they can control many of the bothersome symptoms, such as rapid heart rate, tremors, anxiety, and heat intolerance. Once the hyperthyroidism is under control (by antithyroid drugs, surgery, or radioactive iodine), the beta-blocker is stopped.

Radioactive iodine Destroying the thyroid with radiation, called

radioiodine ablation, is a permanent way to resolve hyperthyroidism. The amount of radiation used is small and does not cause cancer. This is the most widely used treatment in the United States.

Radioiodine is given in liquid or capsule form, and it works by attacking and destroying much of the thyroid tissue. This takes about 6 to 18 weeks. People with severe symptoms, older adults, and people with heart problems should first be treated with an antithyroid drug to control symptoms. Most patients who receive radioiodine develop hypothyroidism and need to take thyroid hormone supplements for the rest of their lives.

As with most treatments, there are some risks:

Sometimes, after apparently successful treatment, the condition returns and further treatment is needed.

About 20 percent of those who use radioiodine treatment require a second dose. These people usually have severe hyperthyroidism or a very large goiter.

Occasionally, people whose hyperthyroidism is caused by Graves' disease may find that their eye symptoms worsen after therapy.

Cont’dPeople who undergo this therapy should

avoid close physical contact, especially with young children and pregnant women, for three to seven days after treatment because of the possibility of exposing them to low doses of radiation. This can be difficult for parents of young children. Patients will need to see their clinician on a regular basis after treatment to have thyroid hormone levels checked and monitor for hypothyroidism or recurrent hyperthyroidism.

VIII. DIAGNOSTIC PROCEDURES

Hypothyroidism Hypothyroidism &&

HyperthyroidismHyperthyroidism

The TSH (or Thyroid Stimulating Hormone) assay has been recognized as an exquisitely sensitive indicator of thyroid status. 

TSH

The T4 (or Thyroxin) assay complements the TSH assay, and is used to confirm a thyroid disorder when suggested by an abnormal TSH. 

T4

The T3 (or Triiodothyronine) assay is another assay which is used in the diagnosis of thyroid disorders. 

T3

The T3 Resin Uptake assay is used in calculating the Free Thyroxin Index (FTI). 

T3 Resin Uptake

Autoantibodies of clinical interest in thyroid disease include thyroid-stimulating antibodies (TSAb), TSH receptor-binding inhibitory immunoglobulins (TBII), antithyroglobulin antibodies (Anti-Tg Ab) and the antithyroid peroxidase antibody (Anti-TPO Ab).

Other Tests

Similar in its use for evaluating a breast mass, ultrasound can be used to assess a thyroid nodule. 

Ultrasound

Fine Needle Aspiration (FNA) has become the single-most important step in the evaluation of a thyroid nodule. 

Fine Needle Aspiration

The thyroid glands' ability to concentrate iodine and certain radioactive isotopes has been exploited in a nuclear imaging technique known as the thyroid scan.

Thyroid Scan

X. DIET

No foods have been shown in clinical studies to improve or worsen the symptoms of hyperthyroidism. However, that doesn't mean you shouldn't pay attention to what you eat. A healthy, well-balanced diet is important for those with hyperthyroidism -- both during and after treatment. It should include things like fruits, vegetables, and lean proteins, with limited amounts of foods high in fat and cholesterol.

Weight Gain and Hyperthyroidism

Healthcare providers generally advise their patients to follow good dietary habits following treatment for hyperthyroidism. The reason is that considerable weight gain is common with this condition. One study showed an average weight gain of about 12 pounds (5.4 kg) in people followed for up to two years after hyperthyroidism treatment.

Factors that seemed to increase the chance for weight gain

included:

Graves' disease Preexisting obesity Previous weight loss as a result of hyperthyroidism

Hypothyroidism following treatment.  

The Well-Balanced DietThe good news is that research has also

shown that this weight gain can be minimized by following sensible dietary habits. If you have an overactive thyroid, you should strive to eat a well-balanced diet and control your weight.

 A well-balanced diet can help you feel better and can be a positive step in dealing with hyperthyroidism. It can also help decrease your chances of developing heart disease or certain types of cancer.

Some suggestions for eating a well-balanced diet and controlling your weight during and after

treatment for an overactive thyroid include the following:

Eat a heart-healthy diet. This diet should include foods such as: Fruits, vegetables, grains, and fat-free or

low-fat milk and milk products Lean meats, poultry, fish, beans, eggs, and

nuts. Limit foods with saturated fats, trans fats,

cholesterol, sodium (salt), and added sugars. Get regular physical activity for at least 30

minutes a day on most days of the week. Limit your intake of alcohol.

END-To God be the Glory-