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Endocrine - Thyroid gland (*Thyroiditis Differentials: HYPO -…

- - - - *Riedel Fibrosing Thyroiditis
        
        Riedell Canal is HARD ice, painless when you fall though
        
        this is the differential for young people P/C with very hard thyroiditis that is non painful (benign)
        --> in elderly though this exact same presentation is usually poorly diffferentiated thyroid CA
      - Congenital = cretinism hypothyroidism
        
        seen in kids once their maternal T4 levels are gone
        --> and they can't produce their own
        
        Congenital hypothyroidism = HYPROthyroidism
        
        protruding 6 Ps
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
      - Primary vs Secondary Hypothyroidism
        
        primary organ = thyroid gland
        --> classic low T4 high TSH
        
        secondary hypothyroidism = Hypothal or Pituitary
        --> low levels of TRH, and all other downstream hormones
        
        Primary Hypothyroidism
        
        primary organ = thyroid gland
        
        classic low T4 high TSH
        
        Clinical Cases
        
        Clinical Case
        
        Notes:
        
        note that
        
        Clinical Case
        
        Secondary = CENTRAL Hypothyroidism
        
        secondary hypothyroidism = Hypothal or Pituitary
        --> low levels of both t4 and TRH
        --> also all other downstream hormones
        
        main other hormones affected = ACTH
        --> this is key and can give alopecia since ACTH is a derivative of POMC that effects melanocytes
        
        also low levels of sex hormones like DHEA from the ant pit can give
        --> alopecia = hair loss
        
        Clinical Cases
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
        
        *POMC and ACTH in hypothyroidism
        
        ACTH is a derivative of POMC
        --> this is key and can give alopecia since ACTH is a derivative of POMC that effects melanocytes
      - *Hashimoto HYPO thyroidism:
        
        Thyroiditis type 2 = Autoimmune Hashimoto
        --> enlarged thyroid
        --> PAINLESS enlarged thyroid
        --> NO illness or preceding event
        --> HYPO thyroid dominant symptoms
        
        *Hashimotos Disease presntation
        -
        
        HASH TAG MOTO with THIGHS THIGH DROID is battling the other THIGH DROIDs in the MOTO ARENA
        other THIGH DROIDS in the battle are
        
        ANTI TPO THIGH DROID who uses H2O2 GUNS to kill the other THIGH DROIDS
        
        then there is ANTI THIGH DROID GOBLIN who is a sneaky GOBLIN driver
        
        in the STANDS watching the HASHTAG MOTO THIGH DROIDS battle are the NUNTENDER LARGE THYROID NUN
        
        NUNTENDER LARGE THYROID NUN is crazy and loves watching HASH TAG MOTO THIGH DROIDS battle each other
        
        NUNTENDER LARGE THYROID NUN sits on her NUN HODGE KING with LIME FOAM
        --> increase NUN HODGE KING LIME FOAM cancer in HASTAG MOTO
        
        NUNTENDER LARGE THYROID NUN is also HIGH FIVING a HULA HOOPING HIGH 5 DR
        --> HLA DR5 in HASH TAG MOTO
        
        *Hashimotos Disease tx
        -
        
        Diffuse lymphocytic infiltration of thyroid with WELL developed GERM CENTRES
        
        seen in autoimmune Hashimoto HYPO thyroidism
        
        *Inflammatory Granuloma POST VIRAL thyroidism:
        
        POST VIRAL Thyroiditis = Inflammatory Granuloma formatiion enlarged thyroid
        --> presents as PAINFUL enlarged thyroid
        --> following a Viral illness
        --> HYPER thyroid dominant symptoms
      - *Hypercholesteremia in HYPOthyroid
        
        there is a decrease in LDL receptors in HYPOthyroid
        
        think in HYPO thyroid everything gets BIGGER, SLOWER, and KEPT IN the body
        --> weight gain
        --> constipation
        --> tired and fatigued
        
        the 2 exceptions though are:
        --> menorrhagia in women (blood leaves the body)
        --> get lower LDL receptors leading to HYPERcholesterol
      - *Levothyroxine tx for HYPO thyroid
        
        levothyroxine = T4 analogue
        --> this is important that it is T4 and not T3
        --> since T4 to t3 conversion in peripheral tissues is done by the body so it maintains the proer dose
        
        note that levothyroxine levels are monitored by the response of TSH to it
        --> so if someone has a hypothyroid and they are on levothyroxine
        --> if their TSH gets way too low, this indicates that you have to lower the t3 levo dose
        
        High Dose levothyroxine
        
        note that levothyroxine levels are monitored by the response of TSH to it
        --> so if someone has a hypothyroid and they are on levothyroxine
        --> if their TSH gets way too low, this indicates that you have to lower the t3 levo dose
        
        puts at risk of all the hyperthyroid dangers
        --> atrial fibrillation is the most common and most dangerous one
        
        Clinical Cases
        
        Clinical Case
        
        Clinical Case
        
        Notes:
        
        note that
  - - - *Graves Disease
        
        most common cause of hyperthyroidism
        
        *Drugs for Hyperthyroidism and synthesis of t3/t4
        -
        
        1 more item...
        
        1 more item...
        
        Graves Disease Tx
        
        GRAVES TREATMENT leads to a GRAVES DISEASE FRANKENSTEIN that has gotten out of HAND
        
        he STEPS on the TSH lab BOTTLE
        
        T3 and T4 FORK JUMP UP HIGH to try and escape the GRAVES DISEASE FRANKENSTEIN
        
        RADIOACTIVE GUYS get called in to clear up the situation with GRAVES DISEASE FRANKENSTEIN
        
        RADIOACTIVE IODINE GUYS diagnose GRAVES FRANKENSTEIN first
        --> see if he ABSORBS the IODONE they spray at him
        --> he ABSORBS the RADIOACTIVE IODINE and they confirm he is a GRAVES DISEASE FRANKNSTEIN
        
        RADIOACTIVE IODINE GUYS then KILL GRAVES FRANKENSTEIN by spraying him with RADIOACTIVE IODINE
        
        1 more item...
        
        Graves Disease presentation
        
        GRAVES DISEASE FUNERAL with the young women who PAY the GRAVE DISEASE a 20 to keep CRYING while they drink their 40s at the GRAVES DISEASE FUNERAL
        
        CRYING with their OPTHALMO and EXTRUDING X EYES
        --> opthalmopathy
        --> exopthalmos
        
        they want TISSUE and grab the GRAVE FUNERAL ANTI TSH TISSUE BOX receptor who is trying to leave the GRAVE FUNERAL
        
        the GRAVE FUNERAL 2 CRYING SISTERS get so DRUNK that they try and bury the THYROOIDS bet GOITRE GOAT with him ALIVE
        
        meanwhile in the corner of the GRAVES FUNERAL there is a PRAYING TIBETAN MIXER MONK praying for the GRAVE FUNERAL HYPERTHYROID
        
        PRAYING TIBETAN MIXER MONK at the GRAVES DISEASE THYROID FUNERAL
        --> pretibial mixodema
        
        *Exopthalmos and pretibial myxedema
        
        note the exopthalmos and the pretibial myxedema are from the excess activity of fibroblasts fromt he IgG stimulating the TSH receptors there
        
        it is NOT from the excess Thyroid hormone
        
        the increase in the TSH receptors behind the eyes and in front of the shins = pretibial area
        --> these increase the activity of fibroblasts
        --> fibroblasts relese glycosaminoglycans
        --> this is the main driving factor and causes inflammation and swelling
        --> leads to BOTH exopthalmos and pretibial myxedema
      - *HYPO cholesteremia in HYPER thyroid
        
        there is an increase in LDL receptors in HYPER thyroid
        
        think in HYPER thyroid everything gets SKINNIER, FASTER, and LEAVES the body
        --> weight loss
        --> HOT all the time
        --> diarrhea
        --> anxiety
        
        the 2 exceptions though are:
        --> amennorhea in women (blood leaves the body)
        --> get higher LDL receptors leading to HYPOcholesterol
      - *Exogenous Hyperthyroidism
        
        you must always consider exogenous hyper thyroid in patients who are anorexic or bulemic or just want to lose weight
        
        important to know if a close family member has thyroxine tablets that they may steal and use
- - - - *Reverse T3
        
        note that most T4 is converted to triiodo t3 = active form
        
        there is also an INACTIVE for of t3 = REVERSE T3
        --> this cannot be made in the thyroid
        --> it can ONLY be made from t4 in the periphery
  - - - *Estrogen increases TBG = thyroid binding proteins
        
        this is the reason for hyperthyroidism during pregnancy
        
        most women just get an increase in PBGs and
        --> get a slight reduction in free t4
        --> the posterior pit releases more TSH to make more t4 and t3
        --> the extra t4 and t3 saturate the newly made TBPs
        --> free thyroid returns to nromal = euthyroid
        --> then TSH also returns to normal levels
- - - - High/Normal TSH
      - Low TSH
  - - - High TSH
        
        Primary Hypothyroidism
        
        high TSH
        
        low T4 and T3
      - Low / Normal TSH
        
        Secondary Hypothyroidism
        
        Normal TSH
        
        low T4 and T3
        
        --> test for
        
        **?
        
        High TSH
        
        Low / Normal TSH