Transcript 03 Hyperthyroid Case Studies

NURS 870 – Spring 2016
Case 1
 A 50-year-old man presents with enlargement of left
anterior neck. He has noted increased appetite over
past month with no weight gain, and more frequent
bowel movements over the same period
PE
 He is 5'8" tall and weighs 150 lb
 The heart rate is 82 and the blood pressure is 110/76
 There is an ocular stare with a slight lid lag
 The thyroid gland is asymmetric to palpation. There is
a 3 x 2.5 cm firm nodule in left lobe of the thyroid
PollEv:
 What do you think the patient's primary problem is?
Probable Diagnosis
 Hyperthyroidism
 The history of increased appetite (without weight gain) and
increased bowel motility is classic for hyperthyroidism
 The resting heart rate is mildly elevated, which is consistent
but is a common finding in primary care offices
 The findings of an ocular stare, lid lag, and an enlarged
thryoid are also consistent with hyperthyroidism


The orbital symptoms noted here are most typically associated with
Grave's disease and result from inflammation and swelling of retroorbital tissues (this effect is separate from the elevation in thryoid
hormone).
In this case the thyroid is asymmetrical and contains a nodule,
whereas the thyroid gland in Grave's disease is symmetrically
enlarged and homogeneous
Hyperthyroidism
Graves Disease
Thyroid Nodule
 Exophthalmos
 Goiter
Exophthalmos
Diagnostic Evaluation
 TSH: Will be decreased
 Free T4 can confirm TSH
 Consider a serum Ca+
 May be elevated in parathyroid adenoma

Would also see increased alk phosphotase here
Diagnostic Evaluation
Diagnostic Results
 Patient's value Reference range
Calcium, total (S) 10.6 mg/dl 8.4 - 10.2
Phosphorus 4.8 mg/dl 2.7 - 4.5
Alkaline phosphatase (S) 160 U/L 49 - 120
T4, Total (S) 12.2 ug/dl 5 - 11.5
T3 resin uptake (S) 35% 25 - 35
T3, Total (S) 311 ng/dl 100 - 215
TSH (S) <0.1 uU/ml 0.7 -7.0
Free thyroxine index (FTI) 14.6 6 - 11.5
What’s the Problem?
 The most important result is the strongly suppressed
TSH
 The remainder of the thyroid tests are also consistent
with hyperthyroidism (elevated FTI and T3)
 The tests for parathyroid problems do not rule out a
parathyroid process (though the alkaline phosphatase
is only very mildly elevated
What additional tests would you
order?
 Additional testing should directly address the possibility of
Grave's disease and should also determine the nature of the
nodule associated with the thyroid (testing so far has been
inconclusive regarding the nodule).
 Grave's disease is strongly associated with the presence of
anti-thyroid microsomal antibodies, while other antibodies
against thyroid epitopes (e.g., thyroglobulin) occur in
Hashimoto's thyroiditis.
 Furthermore, the thyroid hyperfunction that occurs in
Grave's disease can be assessed directly by measuring the
rate radio-iodine uptake into the thyroid gland
Anti-Thyroid Antibody Testing
Test
Normal
Patient Results
Antithyroglobulin
Ab.
Neg
Neg
Thyroid scan
5-28% uptake
68% and 54%;
homogenous
increase with
decrease at the
nodule
Results
 Consistent with Grave’s Disease
 The anti-thyroid antibody tests and radio-iodine
uptake results make a diagnosis of Grave's disease solid
at this point.
 However, the finding that radio-iodine uptake is
decreased in the area of the nodule suggests that there
is an additional problem in the thyroid gland that is
separate from Grave's disease
PollEv:
 Would you want any further testing?
Further Testing
 The finding of a low radio-iodine uptake into the
palpable nodule suggests that a thyroid neoplasm
might be present.
 A tissue diagnosis is needed to fully evaluate that
possibility, so a fine needle aspirate (FNA) of the
nodule was made and the cytology of the recovered
cells was examined.
 The diagnosis from the FNA was papillary carcinoma
of the thyroid, and the final diagnosis for the patient
was Grave's disease with papillary carcinoma
Course
 The patient underwent surgical thyroidectomy
followed by thyroid hormone replacement therapy.
 Later, he was scanned for residual thyroid tissue,
which was ablated with iodine-131.
 He underwent periodic serum thyroglobulin analysis
and iodine-131 scans, which remained negative over a
two-year course
Reminders
 Grave's disease is a systemic autoimmune process that
has hyperthyroidism as one of it's manifestations.
 The removal of the thyroid gland cures the
hyperthyroidism, but not the other symptoms of
Grave's disease--which include the ocular symptoms.
Case 2: PollEv:
 A twenty year old male presents with chief complaint
of fatigue and shakiness/nervousness, elevated heart
rate and inability to gain weight/muscle despite his
attempts to workout.
 2a: What are you looking for in PE?
 2b: What diagnostics will you order?
Case 2: PollEv:
 PE: WNL, no palpable goiter or thyroid nodule. HR is
110
 TSH is 15
 Free T4 is elevated
 EKG – normal except mild tachycardia
 2c: What is your preliminary diagnosis?
Case 2: PollEv:
 PE: WNL, no palpable goiter or thyroid nodule. HR is
110
 TSH is 15
 Free T4 is elevated
 EKG – normal except mild tachycardia
 2c: What is your preliminary diagnosis?
Case 2: PollEv:
Case 2: PollEv:
 Thyroid auto-antibodies POSITIVE
 Patient diagnosed with auto-immune, or Hashimoto’s
thyroiditis.
 2d: What is your treatment plan?
Case 2: PollEv:
 2e: The NP decides to refer the patient to
Endocrinology for further evaluation and
management, but can’t get the patient in for 3 weeks.
 What can we do to help the patient with his symptoms
of nervousness/tremulousness and mild tachycardia?