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Endocrine - Thyroid gland (*Thyroiditis Differentials: HYPO -…
Endocrine - Thyroid gland
*Thyroiditis Differentials:
HYPO - THYROIDISM
in adults --> 2 groups
--> Inflammatory Granuloma formatiion enlarged thyroid
--> Autoimmune Hashimoto enlarged thyroid
Thyroiditis
type 1
=
Inflammatory Granuloma
formatiion enlarged thyroid
--> presents as
PAINFUL
enlarged thyroid
-->
POST VIRAL
thyroiditis
-->
HYPER
thyroid dominant symptoms dominate at
first
-->
HYPO
thyroid dominant symptoms dominate
second
Thyroiditis
type 2
=
Autoimmune Hashimoto
enlarged thyroid
-->
PAINLESS
enlarged thyroid
--> NO illness or preceding event
--> HYPO thyroid dominant symptoms
HYPER - THYROIDISM
in adults --> 2 groups
HYPOTHYROIDISM
in adults --> 2 groups
Thyroiditis
type 1
=
Inflammatory Granuloma
formatiion enlarged thyroid
--> presents as
PAINFUL
enlarged thyroid
-->
POST VIRAL
thyroiditis
-->
HYPER
thyroid dominant symptoms dominate at
first
-->
HYPO
thyroid dominant symptoms dominate
second
Thyroiditis
type 2
=
Autoimmune GRAVES disease
enlarged thyroid
*HYPO thyroidism
*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
Thyroid *Storm
THYROID STORM GOD wrecking havoc on all the people down below and how they DEFEATED HIM
-
*HYPER thyroidism
there is an increase in LDL receptors in HYPER thyroid
think in HYPER thyroid everything gets SKINNIER, FASTER, and LEAVES the body
HYPERthyroiodism = EVERYTHING a WOMAN WANTS...
--> 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
*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
*Anatomy of Thyroid
arteries and nerves to the thyroid gland
recurrent laryngeal loop around and enter the thyroid area from below
--> it then goes into the thyroid and arytenoid cartilage to supply all the laryngeal muscles of the vocal cords etc.
*Blood vessels and nerve of the Thyroid
arteries and nerves to the thyroid gland
recurrent laryngeal loop around and enter the thyroid area from below
--> it then goes into the thyroid and arytenoid cartilage to supply all the laryngeal muscles of the vocal cords etc.
--> note ONLY the cricothyroid is supplied by the ?
inferior thyroid artery runs right by the recurrent laryngeal
*T3 and T4 - Thyroid Hormones production
thyroglobulin is a protein that gathers BOTH iodine and tyrosine
--> binds tyrosine to iodine
--> makes both DIT = diiodotyrosine + MIT = monoiodotyrosine
T3 = MIT + DIT
T4 = DIT + DIT
*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
*T4, t3 TBPs
t4 is the main transported form of thyroid hormone
t3 is the active form of thyroid hormone
TBG = thyroid binding proteins
--> these make up 70% of the binding
rest is done by albumin and other proteins int he blood
*TBG = thyroid binding proteins
these make up 70% of the binding
rest is done by albumin and other proteins int he blood
*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
*Investogation and Dx of Thyroid Problems
always measure TSH levels first before t4 and t3
small changes in T4 lead to big changes in TSH
--> thus it is a more sensitive test for BOTH hyper and hypothyroidism
*Hyperthyroidism presentation
-
TSH
?
High/Normal TSH
Low TSH
*Hypothyroidism presentation
-
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