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Family Medicine > Case 5: Palpitations > Flashcards

Case 5: Palpitations Flashcards

1
Q

Hyperthyroidism pathophysiology

A

Increased T3/T4 that causes symptoms due to

a) thyroid hormone’s stimulation of catabolism
b) enhancement of sensitivity to catecholamines

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2
Q

Hyperthyroidism signs in pts under 50 (9)

A
  • heat intolerance
  • tachycardia
  • fatigue
  • weight loss
  • tremor
  • increased sweating
  • exertional dyspnea
  • decreased menses
  • diarrhea
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3
Q

Older patients (>70) symptoms of hyperthyroidism

A
  • sinus tachycardia
  • fatigue or insomnia
  • asymptomatic
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4
Q

exophthalmos = proptosis

A

Most often seen in Grave’s

either bilateral or unilateral

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5
Q

Causes of enlarged thyroid = goiter

A
  • lack of iodine
  • hypothyroidism
  • hyperthyroidism
  • nodules (single or multiple)
  • thyroid cancer
  • pregnancy
  • thyroiditis
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6
Q

Lack of iodine

A

Worldwide most common cause of goiter and also causes developmental delay and mental retardation

  • most affected in N Africa and Pakistan
  • prevent with supplemental iodine
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7
Q

Clonus

A

Series of abnormal reflex movements of the foot induced by sudden dorsiflexion causing alternate contraction and relaxation of gastrocnemius and soleus muscles

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8
Q

HPA axis effect on thyroid

A

Hypothalamus secretes TRH which stimulates pituitary to produce TSH which stimulates thyroid gland to release T3 and T4

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9
Q

TSH increased

T4 decreased

A

Hypothyroidism

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10
Q

TSH mildly elevated

T4 normal

A

Subclinical hypothyroidism

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11
Q

TSH normal

T4 increased

A 
Pituitary adenoma (TSH producing) OR thyroid hormone resistance
- need to assess Sx further
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12
Q

TSH decreased

T4 increased

A

Hyperthyroidism

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13
Q

TSH decreased

T4 decreased

A 
Central hypothyroidism (TRH deficiency) or
Pituitary hypothyroidism (TSH deficiency)
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14
Q

TSH decreased
T4 normal
T3 increased

A

T3 toxicosis

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15
Q

Primary symptoms of eye manifestations of Graves

A

Related to corneal irritation from eyelid retraction

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16
Q

Special info about exopthalmos

A
  • While 50% of patients with Graves’ have some eye involvement by MRI, only about 20-30% of those are clinically relevant.
  • In up to 10% the eye manifestations can happen when the patient is euthyroid or even
    hypothyroid.
  • Treatment of hyperthyroidism does not affect the eye manifestations.
  • In fact, in some
    patients who get radioactive iodine, will experience worsening symptomatology.
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17
Q

Graves’ Disease

A
  • autoimmune disease in which thyrotropin receptor Abs (thyroid stimulating Igs) are produced –> make more thyroid hormone
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18
Q

Graves’ epidemiology

A
  • women 5-10x more likely to get it
  • peak incidence between 40-60
  • often occurs w family Hx of thyroid disease
  • can be associated with other autoimmune diseases
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19
Q

Graves’ triggers include (3)

A
  • stressful life events
  • high iodine intake
  • recent pregnancy
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20
Q

Sx of hypothyroidism (5) due to slow metabolism

A
  • weight gain
  • cold intolerance
  • pedal edema
  • heavy periods
  • fatigue
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21
Q

Fatigue present in hyper, hypo, or both

A

Present in both hyper and hypothyroidism

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22
Q

How to elicit lid lag

A
  • patient follows your finger w eyes: move finger from upper to lower field of vision - upper eyelid will lag behind upper edge of iris as eye moves downward
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23
Q

Pay special attention to Hx if (2)

A
  • teenager was giving history of abstinence in presence of parent
  • partner in room
24
Q

Cardiac causes of palpitations

A
  • arrhythmia
  • cardiomyopathy
  • hypovolemia
25
Q

Psych causes of palpitations

A
  • anxiety

- panic attacks

26
Q

Med causes of palpitations

A
  • caffeine
  • stimulants
  • theophylline
  • albuterol
27
Q

Substance causes of palpitations

A
  • tobacco
  • caffeine
  • alcohol intox
  • alcohol withdrawal
  • cocaine
28
Q

Endocrine causes of palpitations

A
  • hyperthyroidism
  • pheochromocytoma
  • hypoglycemia
29
Q

Hematologic causes of palpitations

A
  • anemia
30
Q

Infectious causes of palpitations

A
  • febrile illness
31
Q

Cardiac arrhythmias

A
  • cause palpitations when HR is fast

- can be assoc with dizziness or SOB

32
Q

How to differentiate anxiety/panic disorder from hyperthyroidism

A

Hyperthyroidism will have presence of systemic symptoms such as weight loss, changes in stool, changes in menses

33
Q

Anemia causes palpitations because of…

Associated with…

A
  • sinus tachycardia due to reduced oxygen carrying capacity in blood (also causes dyspnea this way)
  • positional dizziness (unlike hyperthyroidism)
34
Q

Causes of anemia

A
  • weight loss leading to nutritional deficiencies (B12, folate)
  • malignancy
  • heavy periods
  • bleeding from GI tract
35
Q

Palpitations due to drugs(meth, cocaine)/caffeine

A
  • pupil dilation
  • increased energy
  • increased BP
  • erratic behavior
36
Q

Common causes of hyperthyroidism (5)

A
  1. Toxic diffuse goiter
  2. Toxic nodular goiter
  3. Thyroiditis
  4. Excessive iodine ingestion
  5. Drug induced hyperthyroidism
37
Q

Toxic diffuse goiter (Grave’s)

A

Autoimmune disease: antibody acts @ TSH receptor –> gland synthesizes excess thyroid hormone
Features include:
- hypervascularity of thryoid that results in bruit or thrill upon auscultation
- Exophthalmos
- Pretibial myxedema (deposition of hyaluronic acid in dermis and subcutaneous tissue)

38
Q

Toxic nodular goiter

A

Older patients have multinodular disease

Younger patients have solitary nodules (can be associated with iodine deficiency)

39
Q

Excessive iodine ingestion

A

Through diet or drug: amiodarone

This can induce thyroiditis

40
Q

Radioactive iodine uptake test and scan

A

Measures amount of radioactive iodine taken up by the thyroid in 24 hrs - allow for differentiation between various etiologies of hyperthyroidism

41
Q

Normal RAIU uptake

A

15-30% of ingested dose

42
Q

High RAIU (>30%)

A

Increased creation of thyroid hormone results in increased radioactive iodine uptake used to synthesize thyroid hormone

  • Graves
  • Active nodules
  • TSH secreting pituitary tumor
  • HCG secreting tumor
43
Q

Low RAIU (<15%)

A

Excess circulating thyroid hormone in thyroiditis leads to leakage of hormone so radioactive iodine is low

  • thyroiditis
  • exogenous L thyroxine
  • struma ovarii
  • amiodarone
44
Q

Studies not used to determine etiology of hyperthyroidism

A

Ultrasound, MRI

45
Q

Ultrasound of thyroid indicated for

A

Evaluation of nodules and thyroid enlargement (but not hyperthyroidism), stratify risk of malignancy, guide FNA

Starting to use color flow Doppler ultrasound to replace RAI when it is not available or contraindicated

46
Q

Pregnancy and thyroid treatment

A

PTU first trimester

Methimazole after

47
Q

Most commonly used medication to suppress thyroid function

A

Methimazole

48
Q

Methimazole side effects

A

Agranulocytosis: bone marrow stops producing white blood cells - patient is vulnerable to serious infecitons

49
Q

How long does it take to suppress thyroid production in hyperthyroid patients?

A

3 months, but symptom relief typically occurs within one month

50
Q

Hyperthyroid patients need to stay on medications for…

A

Several years - more than 1/2 will return to hyperthyroidism if they try to stop medications

51
Q

Treatment of Graves’ disease

A

1) Meds such as methimazole or PTU (Europe)

2) Oral dose of radioactive iodine (US)

52
Q

Radioactive iodine

A

Alternative to thyroid hormone suppressant medication
Iodine destroys most overactive thyroid cells - the level of thyroid hormone falls and the gland shrinks in size
- may have too little functioning thyroid and need thyroid hormone replacement - warn patients of hypothyroid symptoms
- once TSH is in normal range, can check once yearly

53
Q

Radioactive iodine precautions with pregnancy

A
  • obtain pregnancy test first
  • patients should not be near pregnant women or young children several days following radioactive iodine treatment bc it is secreted in urine or stool - it will have bad effects on exposed kids thyroids
54
Q

Radioactive iodine side effects

A
  • transient soreness of neck or brief worsening of symptoms but should resolve in few days
  • worsening eye sx in pts w opthalmopathy
55
Q

Draw TSH post radioactive iodine..

A

once every 2-3 months until it stabilizes

- once in normal range, check once yearly

56
Q

Thyroid replacement thyroid

A

Thyroxine in primary hypothyroidism (this is what follows radioactive treatment)

57
Q

How to dose and manage thyroxine in hypothyroid patient

A
  • 1.5-1.8 mcg/kg
  • increase dose slowly
  • repeat TSH in 6 weeks
  • when stable TSH level achieved, check TSH 1-2/year

Note: some people who have RAI will have enough thyroid left to relapse - occasionally they need a second treatment

Family Medicine (10 decks)

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