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Thyroid Disorder - Coggle Diagram
Thyroid Disorder
Case 1
PCI
Management of subclinical hypothyroidism with antithyroid drugs (Levothyroxine)
Diagnosis
Subclinical Hypothyroidism (HASHIMOTO Disease)
Justification
TSH Level
The TSH level was slightly high indicating subclinical hypothyroidism thus it is Hashimoto disease.
Sign And Symptoms
Large and painless swelling in her neck
Thyroid was diffusely enlarged and rubbery consistency
T3 & T4 Level
Normal
Present of antibody
Presence of high titre antibodies to thyroid peroxidase indicate autoimmune disease so it could be Hashimoto disease
Goal of Treatment
Reduce the TSH level to normal
Improve the signs and symptoms such as reducing the enlargement of goitre
Normalize the antibodies level
Available Option For Treatment
Pharmacological Treatment
1st choice
levothyroxine
effective in reducing the thyroid gland size/ goiter
Initially starts with 25 ug of levothyroxine sodium oral OD with close monitoring.
Then,it may increase by 25-50 mcg at approx 3- to 4-wk intervals until the thyroid deficiency is corrected.
Maintenance: 100-200 mcg/day
2nd choice
thyroidotomy
It was not performed straight away because the pharmacological treatment (L-thyroxine) is initiated to treat the goiter. The surgery is not recommended to be the first line treatment because in total-thyroidectomy the patient’s body will not be able to produce thyroid hormones.
Thus she will be drug dependent for the rest of her life. After the pharmacological treatment starts, we should monitor the patient’s goiter condition and the TSH level to decide whether surgery is required or not with the patient’s consent.
Surgery is recommended when goitres are large, causing compressive symptoms and for cosmetic reasons.
Unless total thyroidectomy is done, recurrence rate is high and subsequent surgery carries a higher risk of complications.
But if the patient insists that she wants to do surgery (e.g. cosmetic reasons), then the surgery could be done right away. Surgery is the ultimate way to overcome his issue.
Non-pharmacological Treatment
we put the patient under the autoimmune paleo (AIP) diet.
In this diet, patient can take:
vegetables except nightshades
All proteins (poultry, eggs, beef, pork, seafood, etc.)
Non-dairy fermented foods (like apple cider vinegar or kombucha)
Herbs (like garlic and turmeric)
Gelatin, bone broth, and arrowroot starch
Green tea
Small amounts of honey, maple syrup, and fruits
Supplements
Eat foods rich in iodine such as
iodized salt
Fish and seafoods
Dairy products
Patient Education
Side effect of levothyroxine
Headache
excessive sweating
Heat sensitivity
Weight loss
Nervousness
Anxiety
Dose and time of levothyroxine to be taken by this patient
25 ug of levothyroxine sodium oral OD
Morning
Ideally 30 minutes before breakfast
Suggested time - 9am
If patient forget to take the medicine
Can take the other time on the same day because this medicine is taken once daily
In case forget totally for the daily dose
just continue take the next dose for the next day
Patient should not double the dose if missed this daily dose
Strict diet by this patient
Autoimmune Paleo (AIP) diet
Patient should take:
vegetables except nightshades
All proteins (poultry, eggs, beef, pork, seafood, etc.)
Non-dairy fermented foods (like apple cider vinegar or kombucha)
Herbs (like garlic and turmeric)
Gelatin, bone broth, and arrowroot starch
Green tea
Small amounts of honey, maple syrup, and fruits
Supplements
Foods rich in iodine
Diary Products
Iodized salt
Fish and seafoods
Case 2
PCI
Unsuitable antithyroid drugs which cause allergy reaction
New management of hyperthyroidism rather than antithyroid drugs
Diagnosis
Graves’s disease, overt thyrotoxic (moderate)
Justification
Signs and symptoms
Large thyroid gland with a vascular bruit
High blood pressure
High heart rate
Lab findings
Elevated free T4
Goal of treatment
Reduce signs & symptoms
Improve BP level to 120/80
Reduce size of goitre
Reduce pulse rate to 80-100 per minute
Improve patient's lifestyle
Available Option for treatment
Pharmacological Treatment
Radioiodine therapy
It is recommended over surgery because the patient is a professional singer thus surgery would jeopardize his career.
It is taken orally, radioactive iodine is absorbed by your thyroid gland, where it causes the gland to shrink.
This is true because surgery would affect the patient’s voice chords thus putting his career at a risk.
Therefore, in this case radioiodine therapy is recommended to treat hyperthyroidism.
Beta-blockers
are recommended for this patient to improve the symptoms such as increased heart beat and increased pulse rate which are some of the common symptoms for hyperthyroidism.
Thus, we recommend giving propranolol, initiated at 10 to 20 mg every six hours.
The dose should be increased progressively until symptoms are controlled.
In most cases, a dosage of 80 to 320 mg per day is sufficient.
Non-Pharmalogical Treatment
Reduce intake of iodine
Iodide salt
High calorie diet to replace all the burnt calories due to hypermetabolic
Avoid or limit caffeinated drinks as it will cause anxiety
Drink plenty of water or fluids to compensate fluid lost
Avoid or stop smoking cigarette
Patient Education
Side effects of radioiodine therapy
Neck tenderness & swelling
Nausea
Swollen salivary glands
Loss of taste or taste change
Dry mouth / insuffiecient salivary production
Dry Eyes
Excessive tearing from the eyes
Side effect of propranolol
Dizzy or tired
Cold hands or feet
Nausea
Dry eyes
Slower heart rate
Hair loss
Diarrhea
Dose and time of the prescribed drug to be taken by this patient
Propranolol dose
10 to 20 mg every six hours.
Morning
6am
Noon
12pm
Evening
6pm
Late Night
12am
If patient forget to take the medicine
If late about 1 @ 2 hours & still have time around 4 hours before the next dose
Take the medicine immediately
Recalculate the time for the 2nd & 3rd dose of the day
If late around 6 hours and ready for the next dose
Just eat the next dose (10-20mg)
Patient cannot double the dose if missed the first dose
Healthy lifestyle
Reduce intake of iodine such as iodine salt
Drink plenty of water
Avoid of stop smoking cigarette
Eat high calorie diet
Avoid or limit caffeinated drinks