1. - Normal TFT lab values: TSH =0.5 to 5.0, T3 µU/mL, T4 =5-12 µg/dL, - Screening of women over 50 Years with TFT is recommended -SUB-Clinical Hypothyroidism= TSH of 5 to 10 + Normal T4 + NO S/S =NO Rx -SUB-Clinical Thyrotoxicosis= low TSH + Normal T4 + NO S/S -American college of Physicians recommends screening w/ TSH for all Females over 50 years -Dx of PheoChromoCytoma is EXTR-adrenal in 10% of pt., and is Bilateral in 10% of pt. -Rx. of Hyperthyroidism with ANY Cardiac S/S is 1st Propanolol (PO) 2nd Anti-thyroid Rx. -Rx. of intraoperative hypertension is phentolamine(IV) -Rx of intraoperative Hypotension is Normal Saline(IV) Bolus. -MCC of atrial fibrillation in the US is Grave's Disease NOT mitral stenosis. -ALL types of thyroiditis, including Hashimoto's thyroiditis present with Hyperthyroidism 1st, then become hypothyroidism. - TSH, Free T4, & Free T3 are NOT changed during pregnancy. - Levothyroxin dose usually needs to be increased suring pregnancy, or when taking hormone replacement therapy, or OCP in hypothyroid pt. - Amiodarone decrease conversion of T4 to T3--> high T4 and low T3 -->may cause hyper-thyroidism or hypo-thyroidism. - Methimazle is a/w congenital aplasia cutis->During pregnancy switch to I. Propylthiouracil.( METHimazle is not good for pregnant MoTHer), II. Surgery - Levothyroxin should be taken on an empty stomach in the morning with no other pills, as Ca & Fe decrease it's absorption.
2. Symptomatic Hypothyroidism
   1. S/S HYPOthermia+HYPOtension+HYPOventilation+HYPOnatremia+HYPOglycemia =MYXEDEMA COMA
      1. Rx. ABC+ levothyroxine(IV)
   2. S/S Hypothyroidism
      1. High TSH
         1. Low free T4
            1. positive anti-microsomal (aka Anti-Thyroid Peroxidase Antibody=anti-TPO)
            2. Dx. PostPartum Thyroiditis if hx. or recent delivery
            3. 20% stay hypothyroid
            4. 80% recover
            5. Inv. Radio-Active Iodine uptake scan= Reduction= COLD
            6. Diffuse = generalized thyroid
            7. Dx. Hashimoto's thyroiditis
            8. young = Thyroiditis
            9. painful
            10. Dx. Sub-Acute Thyroiditis
            11. Rx. NSAID & Propanolol
            12. Painless
            13. Dx. Painless Thyroiditis
            14. 100% recover
            15. Dx. Iodine Deficiency
            16. localized=nodular
            17. MUST Bx. FNAC
   3. S/S Ob/Gyn
3. Normal Physical Exam especially in an over 50 y. female
   1. High TSH
      1. Normal free T4
         1. Asymptomatic
            1. + Anti-thyroid-Ab.
            2. Abnormal lipid profile
            3. more then 10
            4. Rx. Levothyroxine
            5. + Hx of thyroid CA
            6. Increase Levothyroxine to keep TSH @ a level of 0.1-0.3
            7. 5-10
            8. No Rx. needed
   2. Hx. of stress or illness
      1. Normal TSH
         1. normal T4
            1. low T3
            2. euthyroid sick synd.(May also have low low TSH & T4)
            3. Rx. Repeat Tests in 8 weeks
   3. LOW TSH
      1. Normal free T4 & Normal Bone density test
         1. Asymptomatic
            1. No Rx & Repeat TSH level in 6 weeks
      2. low T4
         1. Dx. pituitary cause=Central hypothyroidism
            1. R/o adrenal insufficiency before Rx. to avoid adrenal crisis
            2. Inv. cortisol level, & sti. test
4. Symptomatic HYPERthyroidism
   1. LOW TSH
      1. HIGH free T4
         1. test for serum Thyroid Receptor Antibodies (TRAb) & Thyroid Stimulating Immunoglobulins (TSI). & Anti-Thyroid Peroxidase Antibody
            1. Positive
            2. Dx. Grave's Disease
            3. very big goiter, or pregnancy not responding to PTU
            4. Rx. Surgery
            5. most cases of graves
            6. Rx. Radioactive ablation and add steroid if moderate to sever eye S/S
            7. Negative
            8. Inv. Radio-Active Iodine uptake scan
            9. INCREAS UPTAKE
            10. FOCAL uptake confirms
            11. Dx. Toxic nodule=less likely CA=No Bx. needed
            12. DECREASE uptake
            13. Dx. excess thyroxine medication
            14. Anti-Thyroid Peroxidase Antibody
            15. Dx. Hashimoto's Thyroiditis
   2. NOrmal TFT
      1. Episodic attacks of Hypertension and hyperthyroidism
         1. Initial test : Bl. Plasma free META-NEPHRINE levles OR 24h Urinary levels of META-NEPHRINE & Catecholamine & Venillyl-Mandilic Acid (VMA)
            1. Dx. PheoChromoCytoma
            2. 1st:Phenoxybenzamine(PO) for 14 days before surgery to Rx. HTN
            3. 2nd step: MRI is better then CT to localize the tumor
            4. Radio-Active Meta-Iodo-Benzyl-Gyanidine (MIBG) Scan can aid in confirming the Dx if Bl., Urine, or imaging tests are equivocal
   3. hx. hyperthyroidism weeks after angiography, S/S Multinodular goiter
      1. Dx. Iodine Induced thyrotoxicosis
         1. cold nodule on thyroid scan
            1. Rx. Self limiting, but can be refractory and sever, I.Probanolo, II.Anti-thyroid Rx, III.Kperchlorate
   4. Fever, tachycardia, arrhythmia, vomiting, diarrhea, dehydration
      1. Dx. Thyroid Strom.
         1. Rx. Propanlol, steroid, amiadorone, anti-thyroid
5. Apathetic thyrotoxicosis= Elderly with mental Status changes, weight loss