SILLIMAN UNIVERSITY MEDICAL SCHOOL MEDICINE WORKSHEET

SUBMITTED TO: Proceso Marc F. Udarbe DATE OF SUBMISSION Se!"e#ber $%& '($) SUBMITTED BY: MEDICINE 3II A*+,- .. Pas/0/,Adr,a- Re1 A. Pa-c2o REPRESENTATIVE CASE Ide-",41,-5 Da"a a 35-year-old saleslady So/rce o4 I-4or#a",o- the patient herself C2,e4 Co#!*,a-": nervousness intoleran!e palpitations MEDICAL HISTORY HPI: 35-year-old saleslady sou"ht !onsultation #e!ause of an anterior ne!$ %ass &ith asso!iated nervousness ta!hy!ardia and preferen!e of air !onditioned roo%s' PHYSICAL E6AMINATION .e-era* s/r+e1: (atient is !ons!ious !oherent oriented not in !ardia! distress V,"a* S,5-s B( ) *3+,-+ %%." (/ ) 01 #p% // ) *2 !p% S7,- 3ar% %oist HEENT (in$ palpe#ral !on4un!tivae &ith 567 lid retra!tion C2es"8L/-5s 8lear #reath sounds Card,o 9dyna%i! pre!ordiu% nor%al rate re"ular rythy% E9"re#,",es DT/ : hypera!tive PRIMARY WORKIN. RULE IN RULE OUT IMPRESSION H1!er"21ro,d,s# H6 CANNOT BE RULED OUT seco-dar1 "o .ra+es: 567 ;e%ale "ender 5.yperthyroidis% D,sease due to <raves disease has a fe%aleto-%ale ratio of --2:*7 567 35 years old 5The typi!al a"e ran"e is 1+-=+ years old' Most affe!ted &o%en are a"ed 3+->+ years'7 P.E 567 The presen!e of a diffusely enlar"ed thyroid "land thyroto?i! si"ns and sy%pto%s to"ether &ith eviden!e of ophthal%opathy !an esta#lish the dia"nosis' O"2er !21s,ca* 4,-d,-5s 567 (alpitations 567 9nterior ne!$ %ass 567 Ta!hy!ardia 567 .eat Intoleran!e 567 @id retra!tion 567 .yperrefle?ia 567 Aervousness LABS B TS. 5C+'+*57 D ;ree T= 53'5+7 D ;ree T3 5>+57 I#a5,-5 RAIU : %ar$edly in!reased upta$e at > days 1= hours diffuse ho%o"enous distri#ution UT; .ypervas!ular thyroid "land

DIFFERENTIAL DIA.NOSES
To9,c Ade-o#a H6 567 ;e%ale "ender 567 35 years old PE @id retra!tion .yperrefle?ia

RATIONAL LABORATORY AND DIA.NOSTIC TEST

Tes" To"a* T) Nor#a* Ra-5e >+-*2* %",dl Pa",e-"<s Res/*" >+5 %",dl I-"er!re"a",o-8Necess,"1 It is ordered pri%arily to help dia"nose hyperthyroidis% and %ay #e ordered to help %onitor the status of a person &ith a $no&n thyroid disorder' The T3 test is usually ordered follo&in" an a#nor%al TS. and T= test' Either the total T3 or the free T3 %ay #e ordered' Sin!e %ost of the T3 is #ound to protein the total T3 !an #e affe!ted #y protein levels and protein #indin" a#ility #ut the free T3 is not' Total T3 is "enerally elevated in hyperthyroidis% and de!reased in hypothyroidis%' The T3 test is not useful in dia"nosin" hypothyroidis% #e!ause levels are not redu!ed until the hypothyroidis% is severe' This test %easures the total a%ount of !ir!ulatin" thyro?ine in the #lood' Thyro?ine a hor%one produ!ed #y the thyroid is also $no&n as T=' 9 hi"h value !an indi!ate hyperthyroidis% a lo& value !an indi!ate hypothyroidis%' ;ree T= %easures the free un#ound thyro?ine levels in the #loodstrea%' ;ree T= is typi!ally elevated in hyperthyroidis% and lo&ered in hypothyroidis%' ;ree or un#ound T= levels represent the level of hor%one availa#le for upta$e and use #y !ells' Be!ause the free levels of T= represent i%%ediately availa#le hor%one free T= is thou"ht to #etter refle!t the patientEs hor%onal status than total T=' A+a,*ab,*, "1 SUM8 AO(. ;reeStandin" @a#s Cos" P=((

To"a* T%

='5-*1'5 u",%l

-'32 u",%l

P=((

FT%

+'20 - *'-> %",dl

3'5+ %",dl

P=((

TSH

+'35-5'5* IU,%l

C+'+*5 IU,%l

ThiS test is the %ost sensitive test of thyroid fun!tion availa#le' The TS. test %easures the a%ount of TS. #ein" se!reted #y the pituitary'

SUM8 AO(. ;reeStandin" @a#s

P=((

In people &hose thyroid produ!es too %u!h thyroid hor%one the pituitary shuts do&n TS. produ!tion leadin" to lo& or even undete!ta#le TS. levels in the #lood' 9n a#nor%ally lo& TS. level su""ests hyperthyroidis%' In people &hose thyroid is not fun!tionin" nor%ally and produ!es too little thyroid hor%one the thyroid !annot respond nor%ally to TS. #y produ!in" thyroid hor%one' 9s a result the pituitary $eeps %a$in" TS. tryin" to "et the thyroid to respond' 9n a#nor%ally hi"h TS. level su""ests hypothyroidis%'
RADIOACTIVE IODINE UPTAKE TEST >RAIU "es"? Mar$edly in!reased upta$e at > and 1= hours diffuse ho%o"enous distri#ution The /9IU test %easures the a%ount of iodine the thyroid !olle!ts fro% the #loodstrea%' It %easures ho& %u!h radioa!tive iodine is ta$en up #y the thyroid "land in a !ertain ti%e period' In the dia"nosis of hyperthyroidis% a hi"h /9IU readin" usually indi!ates an overa!tive thyroid that produ!es too %u!h thyroid hor%one as seen in <ravesE disease or to?i! nodular "oiter an enlar"e%ent of the thyroid "land' 9 lo& /9IU readin" su""ests the thyroid is not overa!tive' Ultrasono"raphy of the thyroid "land is used for initial evaluation of a nodular "oiter #ut it does not differentiate #et&een #eni"n and %ali"nant lesions' SUM8 AO(. ;reeStandin" @a#s

IMA.IN. STUDIES

Unre%ar$a#le

.ypervas!ular thyroid "land

ULTRASOUND

SUM8 AO(. ;reeStandin" @a#s

=5+

OTHER LABORATORT TESTS TO ORDER COMPLETE BLOOD COUNT 9 8B8 !ount &ith differential should #e o#tained at #aseline and &ith the develop%ent of fever or sy%pto%s of infe!tion' <raves disease %ay #e asso!iated &ith nor%o!yti! ane%ia lo&-nor%al to sli"htly depressed total 3B8 !ount &ith relative ly%pho!ytosis and %ono!ytosis lo&-nor%al to sli"htly depressed platelet !ount'

THYOID SCAN 9 thyroid s!an does not test thyroid fun!tion per se #ut instead uses radioa!tive %aterial to !reate a pi!ture of the thyroid' The s!an sho&s the siFe and shape of the thyroid and provides i%a"es of irre"ularities su!h as nodules' Aodules are tu%ors in the thyroid that !an either #e #eni"n or !an!erous and !an so%eti%es produ!e e?!ess thyroid hor%one' THYROID@STIMULATIN. IMMUNO.LOBULIN ANTIBODY TSI is an autoanti#ody present in <ravesE disease the %ost !o%%on !ause of hyperthyroidis%' TSI %i%i!s TS. #y sti%ulatin" the thyroid !ells !ausin" the thyroid "land to se!rete e?!ess hor%one' The TSI test dete!ts TSI !ir!ulatin" in the #lood and is usually %easured in spe!ifi! instan!es in people &ith <ravesE disease-&hen the dia"nosis is o#s!ure durin" pre"nan!y and to deter%ine if re%ission has o!!urred'

FINAL DIA.NOSIS .RAVES DISEASE

HYPERTHYROIDISM SECONDARY TO

THERAPEUTICS Prob*e# L,s" *' 1' 3' =' 5' >' -' (alpitations 9nterior ne!$ %ass Aervousness Ta!hy!ardia .eat intoleran!e @id retra!tion .yperrefle?ia

T2era!e/",c ObAec",+es *' To alleviate patients palpitations 1' To alleviate nervousness 3' To treat the anterior ne!$ %ass =' To alleviate ta!hy!ardia 5' To alleviate .yperrefel?e%ia > To alleviate .eat intoleran!e -'To $eep the eyes %oist

MANA.EMENT

Ad+,ce a-d I-4or#a",o*' Tea!h the patient re"ardin" her disease its !ause ris$ fa!tors si"ns and sy%pto%s and its possi#le !o%pli!ations' 1' E?plain to the patient a#out proper !o%plian!e to treat%ent re"i%en su!h as her %edi!ations and its possi#le side effe!ts' 3' E%phasiFe to the patient the i%portan!e of self !are is an inte"ral part of her daily life' It &ould %ean ta$in" responsi#ility for her o&n health and &ell#ein" &ith support fro% those involved in her !are' It involves the doin" of thin"s that help her to stay fit %aintain "ood physi!al and %ental health prevent illness or a!!idents and effe!tively dealin" &ith %inor ail%ents and lon"-ter% !onditions' =' Involve fa%ily in treat%ent and edu!ate the% on the i%portan!e of providin" e%otional support to the patient' 5' E?plain the i%portan!e of diet or eatin" ha#its %odifi!ations PHARMACOLO.IC MANA.EMENT
Dr/5 Na#e E44,cac1

No-@!2ar#aco*o5,c

Ma-a5e#e-"

Treat%ent involves alleviation of sy%pto%s and !orre!tion of the thyroto?i! state'

*' Monitor I G O 1' Monitor HS every = hours 3' 3at!h out for !o%pli!ations of the disease =' (atient is advised to avoid severe fati"ue althou"h si%ple physi!al e?er!ises are en!oura"ed' 5' S%o$in" !essation' >' /eIuest that she $eep a re!ord of daily &ei"ht' -' Dis!uss adoptin" a hi"h-!alorie diet' Identify food li$es and disli$es as &ell as foods that in!rease diarrhea #efore institutin" a plan to in!rease food inta$e' 2' In!lude fresh and dried fruits nuts and nut #ased spreads ve"eta#les e""s de!affeinated !offees and teas oat%eal !olas &hole "rains and 4a%s and 4ellies in the diet' 0' <ive the patient the opportunity to dis!uss their feelin"s a#out the !han"es in the siFe or shape of #ody i%a"e to i%prove the self-i%a"e' S/r5,ca* Ma-a5e#e-" S/b"o"a* T21ro,dec"o#1 is usually used &ith the intention of leavin" enou"h thyroid re%nants #ehind to avoid hypothyroidis%' It "enerally is reserved for patients &ith lar"e "oiters &ith or &ithout !o%pressive sy%pto%s'

Sa4e"1

S/,"ab,*,"1

Cos"

8ar#i%aFole 5Aeo%er!aFol e7 1+ %" ('O every *1 hours

8ar#i%aFole is an antithyroid a"ent that de!reases the upta$e and !on!entration of inor"ani! iodine #y thyroid it also redu!es the for%ation of diiodothyrosine and thyro?ine' On!e !onverted to its a!tive for% of %ethi%aFole it prevents thyroid pero?idase enFy%e fro% !ouplin" and iodinatin" the tyrosine residues on thyro"lo#ulin

Co-"ra,-d,ca",o-s 8ontraindi!ated in patients &ith a previous history of adverse rea!tions to !ar#i%aFole pre : e?istin" he%atolo"i!al !onditions severe hepati! insuffi!ien!y'

(res!ri#ed for .yperthyroidis%' It redu!es the a%ount of thyroid hor%one'

Prescr,!",o- Wr,",-5

9lvin <' (asuIuin MD Silli%an Medi!al 8enter Du%a"uete 8ity 5+357 115=535 (atient: Date: 9ddress: 9"e,Se?:

9lvin <' (asuIuin MD Silli%an Medi!al 8enter Du%a"uete 8ity 5+357 115=535 (atient: Date: 9ddress: 9"e,Se?:

9lvin <' (asuIuin MD Silli%an Medi!al 8enter Du%a"uete 8ity 5+357 115=535 (atient: Date: 9ddress: 9"e,Se?:

KKKKKKKKKKKKKKK MD @i!' Ao' -*23-+-

KKKKKKKKKKKKKKK MD @i!' Ao' -*23-+-

KKKKKKKKKKKKKKK MD @i!' Ao' -*23-+-

/eferen!es: Bi!$ley 9' et' 9l' 51++07'BatesJ<uide to (hysi!al E?a%ination and .istory Ta$in"' *+thed' 8herne!$y 8 G Ber"er B' 51++27' @a#oratory Test and Dia"nosti! (ro!edures' 5th ed' Saunders Elseviers: (hiladelphia ;au!i 9' et 9l' 51+*17' .arrisonJs (rin!iples of Internal Medi!ine' *2th ed' M!<ra&-.ill Medi!al (u#lishin" Division US9'