Hypothyroidism

Congenital Hypothyroidism
Clx
Initially NORMAL at birth
Symptoms develop after maternal T4 ⤵️:
–       Lethargy
–       Enlarged fontanelle
–       Protruding tongue
–       Umbilical hernia
–       Poor feeding
–       Constipation
–       Dry skin
–       Jaundice
Dx
–       ⤴️ TSH & ⤵️ free T4 levels
–       Newborn screening (mandatory)
Tx
Levothyroxine
o   Sx (weird ones): ⤵️ reflexes, bradycardia
o   Galactorrhea can happen –> TRH can cause ⤴️Prolactin
o   PEx: delayed relaxation of the deep tendon reflex
o   Dx: ⤴️ TSH – ⤵️T4 – Hypercholestrolemia (⤵️ LDL receptor synthesis) – may have megaloblastic anemia
o   Tx: levothyroxine
        • Dosing:
          • Gradual increase in elderly
          • Increase w/ Estrogen or SERM
          • ⤴️ in pregnancy
          • ⤵️  w/ Glucocorticosteroids
        • Check TSH in 6 weeks, DO NOT CHANGE THE DOSE BEFORE THAT
          • if normal –> Maintain the dose
          • If ⤴️ –> Suboptimal –> Increase
          • If ⤵️ –> too much dose –> decrease
o   Hashimoto’s thyroiditis
·       Anti-TPO
·       early in dz, pt may have ⓃTSH + T4
·       ⤴️ dose of thyroxine if pt is pregnant
o   Subacute thyroiditis
·       post flu-like infection –> early look like hyperthyroidism –> hypothyroidism
·       Sx: jaw pain + tooth pain
·       Tx: Aspirin –(in severe cases)–> cortisol
o   Myxedema coma (hypothyroid pt–> coma)
·       EMERGENCY 🚨
·       Sx: Stupor, coma, seizure, hypoventilation in a hypothyroidism pt
·       Tx: IV thyroxine+ hydrocortisone + mechanical ventilation
·       Subclinical hypothyroidism
o   clinical entity with ⤴️TSH but normal T3/T4 values
o   does not require treatment unless  ✳️
        • presence of anti-TPO antibodies 
        • clinical symptoms of hypothyroidism
        • hyperlipidemia
        • menstrual dysfunction
        • TSH >10
Thyroditis
Pain
Hx/PEx/Labs/Dx
RAIU
Tx
Subacute
YES
⤴️ ESR
T4/T3 (⤴️ → ⤵️)
Self-limited
LOW
Aspirin
Severe: prednisone
Lymphocytic
Postpartum
NO!!
Ⓝ ESR
T4/T3 (⤴️ → ⤵️)
Symmetrical enlargement
Self-limited
LOW
BB (Propanolol)
Hashimoto’s
NO
⤴️ TSH ⤵️ T3/T4
⤴️ risk of lymphoma
⊕ Anti-TPO
LOW
Levothyroxine
Reidel’s
NO
Fibrotic thyroid + other parts of the body
Compression sx
⤵️  PTH (hypoPTH),
Dx: Surgical Bx
LOW
Levothyroxine
prednisone
Grave’s
NO
⊕ Exophthalmos
Hyperthyroid
can be dx clx
HIGH (DIFFUSE)
1˚ BB
2˚ Anti-thyroid
3˚ RAIU
3˚ Thyroidectomy
Drug-induced
NO
when you suspect a drug
variable
Stop the drug

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