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Algorithmic Approach to Hypothyroidism - Differential Diagnosis and Management Framework Central Hypothyroidism (Secondary or tertiary) ↓TSH, ↓FT4 • Post-GH therapy, drug-induced • Pituitary adenoma • Craniopharyngioma • Meningioma • Glioma • Germinoma • Immunologic lesions Overt Hypothyroidism ↑TSH, ↓FT4 • Initiate LT4 ≤ 65 yo; no CVD: 1.6 μg/kg daily > 65 yo or CVD: 12.5-25 μg daily • Measure TSH in 4-6 weeks, Titrate LT4 based on TSH Subclinical Hypothyroidism ↑TSH, ↔FT4 • Recheck TSH after 2-3 months and obtain TPOAb Euthyroid sick syndrome ↔TSH, ↓FT3/↓FT4 • Treat acute illness Matthew Ho, MD PhD @MatthewHoMD #Hypothyroidism #Differential #Diagnosis #algorithm #endocrinology #hypothyroid #Management

Hyperthyroidism – symptoms and signs. Symptoms: Weight loss, Increased appetite, Irritability/behaviour change, Restlessness, Malaise, Stiffness, Muscle weakness, Tremor, Choreoathetosis, Breathlessness, Palpitation, Heat intolerance, Itching, Thirst, Vomiting, Diarrhoea, Eye complaints, Goitre, Oligomenorrhoea, Loss of libido, Gynaecomastia, Onycholysis, Tall stature (in children), Sweating Signs: Tremor, Hyperkinesis, Psychosis, Tachycardia or atrial fibrillation, Full pulse, Warm vasodilated peripheries, Systolic hypertension, Cardiac failure, Exophthalmos, Lid lag and stare, Conjunctival oedema, Ophthalmoplegia, Periorbital oedema, Goitre, bruit, Weight loss, Proximal myopathy, Proximal muscle wasting, Onycholysis, Palmar erythema, Graves' dermopathy, Thyroid acropachy, Pretibial myxoedema #Hyperthyroidism #Symptoms #Signs #Diagnosis #Endocrinology

REBEL Review 71: Treatment of Thyroid Storm Propranolol Esmolol Propylthiouracil (PTU) Methimazole Saturated Solution of Potassium Iodide (SSKI) Lugol's Solution Sodium Iodide Lithium Dexamethasone Hydrocortisone #endocrinology #thyroidstorm #hyperthyroidism #table #management #treatment #pharmacology #comparison #Dosages #dosing

Hyperthyroidism Overview Clinical Manifestation of Hyperthyroidism: • Fatigue • Weight loss • Heat intolerance • Depression, nervousness • Irritability, anxiety or agitation • Menstrual irregularities • Weakness or tremors • Palpitations • Exertional dyspnea • Hyperdefecation • Anterior neck pain • Insomnia Primary Hyperthyroidism: • Toxic multinodular goiter (Hot nodule) • Toxic uninodular goiter • Toxic diffuse goiter (Graves' disease) • Thyrotoxicosis associated with thyroiditis Secondary Hyperthyroidism: • Factitious thyrotoxicosis • T3 Toxicosis • Iodine loads • Metastatic Follicular CA • Malignancies with circulating thyroid stimulators • TSH-producing pituitary tumors • Struma Ovarii with hyperthyroidism Diagnosis: • ↓ Low TSH • ↑ Total T3 • ↑ Free T4 • Thyroid stimulating immunoglobulin (TSI) or Thyrotropin (TSH) receptor antibodies (TRAb) if Graves' disease is suspected • Thyroid scintigraphy with radioactive iodine uptake • Thyroid US: Vascularity, Nodules, Size Thyroid Storm: • Life threatening: - Tachycardia. Cardiac arrhythmia - Fever (Hyperpyrexia) - Perspiration - Diarrhea - Anxiety, agitation, psychosis - CHF - Hypotension • Labs: - ↓ TSH, ↑ FT4 and/or ↑ T3 - Mild hypercalcemia, Hyperglycemia - ↑ AST/ALT • Treatment: - Beta blocker - Thionamide - Iodine solution - Iodinated radiocontrast agent - Glucocorticoids: Reduce T4 -> T3 - Bile acid sequestrants Hyperthyroidism Physical Examination: • Moist palms • Thickening of skin: pretibial • Bulging eyes (lid retraction or proptosis), unblinking stare • Tremor • Eye irritation, peri orbital edema, diplopia, change in visual acuity • Hyperreflexia • Tachycardia • Tachypnea • Goiter (+/- bruit) • Thyroid thrill • Ophthalmoplegia • Atrial fibrillation/flutter • Abdominal tenderness Treatment: • Beta blockers • Thioamides (Methimazole and PTU) • Radioactive iodine therapy • Thyroidectomy #hyperthyroidism #causes #diagnosis #differential #endocrinology #signs #symptoms #thyroid

Effects of hyperthyroidism and hypothyroidism on renal physiology and function #hyperthyroidism #hypothyroidism #renal #physiology #comparison #effects #nephrology

Hypothyroidism and Hyperthyroidism - Symptoms and Signs Hypothyroidism: - General - From asymptomatic to myxedema coma, “Like everything is slowed down” • Low exercise tolerance • Hyperlipidemia • Cold intolerance • Weight gain (modest) - Neuro • Depression • Memory loss • Fatigue - Face/Neck • Hair is coarse, brittle and is lost • Thinning of lateral 1/3 of eye brows • Puffy Face • Enlarged tongue • Hoarseness • ± Goitre - Cardiovascular • bradycardia • cardiomegaly • pericardial effusion • hypertension - GI • Constipation - Gu: • Menorrhagia - Skin • Skin is dry, coarse, thick, cold, pale - Muscles • Weakness, cramps • Tendon Reflex Delay (relaxation phase) Hyperthyroidism: - General “Like running a marathon all the time” • Appear to have high energy but are fatigued • poor exercise tolerance • Heat intolerance • Weight loss (despite appetite) - Neuro: • Nervousness • Restlessness • Insomnia • Tremour • Increased Reflexes - Face/Neck • ophthalmopathy ocular changes (periorbital swelling, lid retraction and lid lag, stare and infrequent blinking) infiltrative (proptosis/exophthalmos, increased edema of lids and conjunctiva, chemosis, ophthalmoplegia) • ± Diffuse goitre • Bruit (when osculating over thyroid) - Cardiovascular • Palpitations, Afib - GI • Diarrhea - Gu: • Infertility, amenorrhea - Skin • Sweating • Warm, moist skin • Dermatopathy Ø Hands: Acropachy Ø Legs: “pretibial myxedema - Amy Chung, MD, MSc @AmyChung #Hypothyroid #Hyperthyroid #Symptoms #Signs #Diagnosis #endocrinology #Hypothyroidism #Hyperthyroidism

Graves’ Disease: Pathogenesis and Clinical Findings B & T lymphocyte mediated autoimmunity attack TSH receptor -> Continuous stimulation of thyrotropin receptor by circulating autoantibodies -> Increased iodination of thyroglobulin, Thyroid gland hyperplasia Note: B & T lymphocytes also attack other thyroid antigens (thyroglobulin, thyroid peroxidase, Na-I Symporter) but is believed to play little role in the etiology Signs/Symptoms: - Pretibial myxedema - Fat pad: proptosis - Muscle: diplopia - Conjunctiva: conjunctivitis - Decr TSH - Goiter -> Hoarseness, Dysphagia, Thyroid gland bruit #GravesDisease #pathophysiology #endocin #endocrinology #symptoms #signs #diagnosis

Myxedema coma and thyroid storm are thyroid emergencies associated with increased mortality. Prompt recognition of these states—which represent the severe, life-threatening conditions of extremely reduced or elevated circulating thyroid hormone concentrations, respectively—is necessary to initiate treatment. Management of myxedema coma and thyroid storm requires both medical and supportive therapies and should be treated in an intensive care unit setting. Satyendra Dhar MD, @DharSaty #hypothyroidism, #hyperthyroidism, #ICU, #myxedemacoma, #thyroidemergencies, #thyroidstorm

Thyroid Disorders and Menstrual Cycle Function Hypothyroidism • Polymenorrhea (increased menstrual bleeding) is more common • Oligomenorrhea • Anovulation • Hypermenorrhea-menorrhagia • Galactorrhea • Decreased fertility and miscarriage Hyperthyroidism • Amenorrhea / hypomenorrhea most common • Oligomenorrhea • Anovulation • Decreased fertility and risk of miscarriage #Thyroid #Disorders #Menstrual #Cycle #Differential #Diagnosis #Endocrinology

Thyroid Disorders - Differential Diagnosis Algorithm Hypothyroidism: • Hasimoto’s • Radioactive Iodine • Hypopituitarism • Iodine Deficiency • Medications • Surgery • Congenital • Other: Subclinical Hyperthyroidism: • Graves’ • Toxic Nodular • Thyroiditis • Exogenous Hormone • Other - Amy Chung, MD, MSc @AmyChung #Thyroid #Disorders #Differential #Diagnosis #Algorithm #Hypothyroid #Hyperthyroid