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Case Management: ThyroidJoey TabulaMayou Martin TampoKorina Ada Tanyu
General Information
MJA, 35/F, married, right-handed, Roman Catholic, housewife from Infanta, Quezon
Chief complaint:
ABDOMINAL ENLARGEMENT
Patient Profile•No DM, HPN, BA•No vices
DIFFUSE TOXIC GOITER (2007)
anterior neck mass with associated palpitations,
dysphagia, dyspnea, tremors and heat intolerancePTU and Propanolol taken for ~ 6 months with
resolution of symptoms. Discontinued. Lost to follow-up.
6 mo PTC
RECURRENCE palpitationstremorsheat intolerance
Now with...Exertional dyspnea Gradual abdominal
enlargement Progressive bipedal edema.
3 mo PTC 1 day PTC1 wk PTC2 wk PTC
ConsultedAdmitted in Lucena
and allegedly given IV antibiotics.
Discharged improved after 10 days
PTU and propanolol on fair compliance
6 mo PTC
Readmitted for dyspnea and abdominal enlargement.
Given unrecalled meds probably diuretics which decreased the edema
Discharged after 2 days with relief of symptoms.
3 mo PTC 1 day PTC1 wk PTC4 wk PTC
6 mo PTC
Persistence of exertional dyspnea, abdominal enlargement, and bipedal edema.
Now with 2-pillow orthopnea and jaundice.
No consult
3 mo PTC 1 day PTC1 wk PTC4 wk
PTC
6 mo PTC
•1 week prior to consult▫Increase in the severity of the exertional
dyspnea on mild activity, abdominal enlargement, and bipedal edema
▫Now with paroxysmal nocturnal dyspnea▫Consulted at a local hospital in Quezon▫“may tubig sa tiyan”▫Advised transfer to PGH for evaluation and
management
2 mo PTC 1 day PTC1 wk
PTC2 wk PTC
6 mo PTC
Persistence of symptoms2 episodes of vomitingConsult at PGH
2 mo PTC 1 day PTC1 wk PTC2 wk PTC
Review of systems
•(+) weight loss ~50%•(-) loss of consciousness•(-) blurring of vision•(-) dizziness•(-) headache•(-) chest pain•(-) melena/hematochezia
Past and Family History
•Past Medical History▫As above▫(-) PTB▫No known allergies
•Family Medical History▫(+) hypertension – mother▫(+) goiter – sister and brother▫(-) DM, PTB, asthma, heart disease
Personal Social History
•Housewife•With 4 children•No vices
OB-Gyne History
•G5P5 (5005)•LMP: December 15, 2009•PMP: November 2009•Irregular, lasting for ½ month sometimes,
consumes 6 cloths per day•IUD since 2000
Physical Examination at the ER• BP = 140/90, HR = 160s, RR = 24, T = 37.2• Awake, coherent, oriented• Icteric sclerae, pink conjunctivae, (+)
exophthalmos, neck vein engorgement, ANM 10 x 10 cm, non-tender, moves with deglutition
• Equal chest expansion, subcostal and intercostal retractions, bibasal crackles, and rhonchi
• Adynamic precordium, DHS, tachycardic, irregularly irregular rate
• Globular, NABS, soft, nontender, (+) fluid wave• bipedal pitting edema, anasarca, DTR ++
Differentials for HyperthyroidismDifferentials Points for Points against
Graves’ Disease With the above mentioned SSx, especially the ophthalmopathy
Cannot be ruled out
Thyroiditis With the above mentioned SSx
Nontender goiter
Struma ovarii With the abovementioned SSx, abdominal enlargement
No masses palpable on PE
Drug induced hyperthyroidism
With the abovementioned SSx
No history of intake
Other Problems
Differential Points for Points against
Congestive Heart Failure prob sec to TTHD
NVE, ascites, crackles
Cannot be ruled out
Community-acquired pneumonia
Crackles, cough, fever, tachypnea
Cannot be ruled out
Working Impression
Diffuse Toxic Goiter probabaly Graves’ Disease, in storm
Thyrotoxic Heart Disease in CHF FC III
r/o CAP-MRs/p IUD insertion (2000)
AF in
Course at the ER
Diffuse nodular toxic goiter, in storm CHF FC II-III with AF in RVR, t/c CAP-MR
Course at the ER
•Burch and Wartofsky Score (85)▫Temperature – 5▫CNS – 0▫GI – 20▫Precipitant history - 10▫Cardiac (> 140) – 25▫CHF
Edema 5 Bibasal rales 10 AF 10
•Labs done: CBC, RBS, Crea, Na, K, Ca, Mg, Albumin, ALT/AST, PT/PTT, urinalysis, 12 L ECG, xray (chest and abdomen)
•Medications given▫PTU 50 mg tab 12 tabs now then 1 tab TID▫Propanolol 40 mg 1 tab now, then 40 mg tab▫Digoxin 0.25 mg IV now▫Furosemide 40 mg IV▫SSKI 5 drops q6 h, 1 hour post PTU▫Dexamethasone 2 mg IV q6 h
•Referred to POD
Physical Exam at Med-ER• Awake, conscious, coherent• BP = 90/60, HR = 115, RR = 22, T = 37.2• Icteric sclerae, pink palpebral conjuctivae, (+)
anterior neck mass 10 x 10 cm• Equal chest expansion, no retractions, (+) bibasal
crackles• Adynamic precordium, distict heart sound,
tachycardia, irregular rhythm, no murmur• Globular, normoactive bowel sounds, soft, (+)
ascites, no tenderness• Full and equal pulses, pink nailbeds, (+) grade 2
bipedal edema
Course at the Med-ER• Assessment: DTG in storm, thyrotoxic heart disease,
in CHF FC III, AF in VR, t/c CPC of the liver, s/p IUD insertion
• Plan▫NPO except medications▫Keep on moderate high back rest▫ IVF: 1 liter D5NSS x 16 hours▫Side drip: furosemide 100 mg in 100 cc PNSS in soluset
at 4 cc/hr▫Diagnostics: FT4, TSH, add FBS, lipid profile,
holoabdominal UTZ, fecalysis▫Tx: add paracetamol 500 mg tab 1 tab OD q4 prn for T
≥ 38.5
Albumin 22 low Alkaline phosphatase 94 AST 61 high ALT 42 Ca 1.86 low Mg 0.82Glucose 5.6 Crea 131 high Na 133 low K 3.2 low Cl 104PT 11.3/22.4/0.35/2.15APTT 35.8/52.8
U/A dark yellow hazy
1.015 pH 6 trace sug neg prot 0-1 RBC 1-3 WBC 0-1 hyaline casts 0-1 waxy cast occ epith cells neg crystals 1+ bact occ mt Bilirubin 3+ trace ketone
CBC WBC 10.1 3, RBC 6 , Hgb 101, Hct 0.302, MCV 83.7, MCH 28.1, MCHC336, RDW 15.9, PC 201, N 0.7, L 0.15, M 0.14, E 0.01, B 0
CXR: Cardiomegaly LV form
7AM MICU DTG, instormWith TTHD in CHF FC III with AF in RVRWith TTLD
Decreased PTU 2 tabs q6Decreased Propanolol 1 tab TID defer if BP <90/60O2 prn
10 AM Day MHAPOD DTG Grave’s Disease in thyroid stormWith TTHD in CHF FC III with AF in RVRWith TTLD
Same
10:45AM Endo Maintainedr/o CAP
Increased PTU 4 tabs q4Increased SSKI 5 drops q4Increased Propanolol 40 mg q8
11 AM Day MHAPOD Started oral KCl 15 cc TID x 2 cyclesStarted NaCl tab 1 tab BID x 2 days
8:30 PM RIC Maintained Same
3/12/10 Endo Grave’s disease, storm resolvingWith TTHD in CHF FC III with AF in RVRWith TTLDAzotemia probably prerenal from poor intake and 3rd spacing losesAnemia multifactorial, IDA
d/c dexa and SSKIShifted PTU to Methimazole 20 mg q8Continued PropanololStarted Furosemide 40 mg IV q12 or tabDefer for BP <90/60 ideally bumetanideStarted oral KCl 10% 30 cc q8Resume digoxin once electrolyte corrected
3/13/105 PM
RIC Grave’s disease not in stormWith TTHD in CHF FC III with AF in RVRWith TTLD
Home meds:Furo 20 mg bidSpiro 25 mg poPropanolol 10 mg tidPTU 50 mg 2 tabs tidVit D +CaCO3 1 tab bidKalium durule 1 tab tid x 3 days
Laboratories Prior to Discharge
•BUN 21.69, Crea 138, TB 560.56, DB 401.83, IB 158.73, Mg 0.70, Na 137, K 2.7
Discharge Diagnosis
•Graves’ Disease, not in storm•Thyrotoxic Heart Disease in CHF FC III
with Atrial Fibrillation in RVR•t/c Chronic-Passive Congestion of the
Liver•s/p IUD insertion (2000)
Course in the Wards
•Home medications•Furosemide 20 mg 1 tab bid •Spironolactone 25mg 1 tab od•Propanolol 10 mg tid•PTU 50 mg 2 tabs tid•Vitamin D + CaCO3 1 tab bid•Kalium durule TID x 3 d
Management of Thyroid Storm
Introduction
•Thyrotoxicosis▫Elevated thyroid hormone▫Most common causes:
Graves’ Disease (60-80%) Hyperthyroidism Thyroid storm (thyroid crisis)
Introduction
•Hyperthyroidism ≠ Thyrotoxicosis▫Conditions with increased thyroid hormone
but normal thyroid function: Thyroiditis Thyrotoxicosis factitia
Signs and Symptoms• Represent a hypermetabolic state with increased
-adrenergic activity
• Hyperactivity, irritability, dysphoria
• Heat intolerance and sweating• Palpitations• Fatigue and weakness• Weight loss with increased
appetite• Diarrhea• Polyuria
• Oligomenorrhea, loss of libido
• Tachycardia, atrial fibrillation in the elderly
• Tremor• Goiter• Warm, moist skin• Muscle weakness,
proximal myopathy• Lid retraction or lag• Gynecomastia
* in descending order of frequency
Signs and Symptoms
•Other Signs:▫Chest pain – often w/o cardiovascular
disease▫Psychosis▫Disorientation▫Hyperdefacation▫Edema
Signs and Symptoms
•Other Symptoms▫Diaphoresis▫Dehydration▫Fever▫Widened Pulse Pressure▫Thyromegaly
Graves = nontender, diffuse Thyroiditis = tender, diffuse Single nodule or MNG
▫Thyroid bruit
(Brief) Pathophysiology
Etiologies
•Autoimmune•Drug-Induced•Infectious•Idiopathic•Iatrogenic•Malignant
Etiologies
•Autoimmune▫Graves▫Chronic thyroiditis (Hashimoto)▫Subacute thyroiditis (de Quervain)▫Postpartum thyroiditis
Etiologies
•Infectious▫Suppurative thyroiditis▫Postviral thyroiditis
•Idiopathic▫Toxic MNG
2nd most common cause of hyperthyroidism
Etiologies
•Iatrogenic▫Thyrotoxicosis factitia▫Surgery
•Malignant▫Toxic adenoma▫TSH – secreting pituitary tumor▫Struma ovarii
Etiologies• Thyroid storm (classically w/ underlying
Graves or toxic MNG) can be triggered by:▫ Infection▫General surgery▫Cardiovascular events▫Toxemia of pregnancy▫DKA, HHS, insulin-induced hypoglycemia▫Thyroidectomy▫Non-adherence to antithyroid medication▫RAI▫Vigorous palpation of the thyroid gland
Differential Diagnosis
•Anxiety•Panic Disorders•Delirium Tremens•Neuroleptic Malignant Syndrome•CHF•DM
Differential Diagnosis
•Septic Shock•Heat Exhaustion/ Heat Stroke•Munchausen Syndrome•Withdrawal Syndromes•Toxicity
▫Anticholinergics (atropine)▫Selective Serotonin Reuptake Inhibitors
(fluoxetine)▫Sympathomimetics (dopamine)
The Burch-Wartofsky Score
•assess of the probability of thyrotoxicosis independently from the level of thyroid hormones
•temperature, central nervous effect, hepatogastrointestinal, cardiovascular dysfunctin, and history
•> 25 points thyrotoxicosis is possible
•> 45 points, probable
Burch – Wartofsky Criteria
Thermoregulatory Dysfunction
Score Cardiovascular Dysfunction
Score
99-99.9 F (37.2-37.7 C) 5 Tachycardia
100-100.9 F (37.8-38.2 C) 10 99-109 BPM 5
101-101.9 F (38.3-38.8 C) 15 110-119 BPM 10
102-102.9 F (38.9-39.3 C) 20 120-129 BPM 15
103-103.9 F (39.4-39.9 C) 25 130-139 BPM 20
≥ 104 F (>40.0 C) 30 ≥ 140 BPM 25
Central Nervous System Score Congestive Heart Failure Score
Agitation 10 Pedal Edema 5
Delirium/Psychosis/ Lethargy 20 Bibasal Rales 10
Seizure/Coma 30 Pulmonary Edema 15
GI – Hepatic Dysfunction Score Atrial fibrillation Present 10
Diarrhea, Nausea/Vomiting, Abdominal Pain
10 Precipitant History Present
10
Severe jaundice 20
Workup
•In thyroid storm, the diagnosis must be made on the basis of the clinical examination.
•Total T4 not measured▫variations in serum thyroid-binding
proteins alter the ability to interpret results•TFT’s do not distinguish thyrotoxicosis
from thyroid storm
Workup
•Some lab abnormalities in thyroid storm▫Hyperglycemia▫Hypercalcemia▫Hepatic function abnormalities▫Low serum cortisol▫Leukocytosis▫Hypokalemia (in HPP)
Imaging
•CXR▫May identify trigger for thyroid storm, ex.
CHF or pneumonia▫Thyroid scan
Diffuse uptake = Graves Focal uptake = toxic adenoma
Other Diagnostics
•12-L ECG▫Sinus tachycardia (most common)▫AF (often in elderly)▫Complete heart block (rare)
Critical Care
•Prompt institution of treatment▫Hook to cardiac monitor
Arrhythmia may convert to sinus only after antithyroid tx
▫Intubate if profoundly altered sensorium▫Aggressive fluid resuscitation (3-5L/d)
Profound GI and insensible losses▫Thermoregulation with aggressive TSB and
antipyretics Avoid ASA decreased protein binding
increased fT3, fT4
Critical Care
•Antithyroid Treatment▫To prevent synthesis of new thyroid
hormone:▫Load 600 mg PTU then 200-300 mg q6 (PO,
per NGT, per rectum) PTU prevents peripheral conversion of T4T3 Clinical effects may be seen after 1 hour
Critical Care
•Antithyroid Treatment▫To prevent release of preformed hormone:▫1 hour after loading PTU, give stable iodide
Wolff-Chaikoff vs. Jod-Basedow 5 drops SSKI q6 0.5 mg iopodate or iopanoic acid q12 Iodine allergy? Use lithium
Critical Care
•Anti-adrenergic Treatment▫Anti-adrenergic activity to control
symptoms and heart rate High output heart failure
▫Propranolol 40-60 mg PO/NGT or 2 mg IV q4 High dose propranolol inhibits peripheral
conversion of T4T3
Critical Care
•Corticosteroids▫Dexamethasone 2 mg 6h
Inhibits thyroid hormone synthesis Inhibits peripheral conversion of T4T3
▫Suspicion of Adrenal Insufficiency
Inpatient Care
•Admit to ICU•Confirm diagnosis with labs•Clinical improvement a few hours after
therapy•Titrate medications to optimimize
antithyroid and antiadrenergic effects•Aggressively treat infection, underlying
precipitants
Inpatient Care
•Admit to ICU•Confirm diagnosis with labs•Clinical improvement a few hours after
therapy•Titrate medications to optimimize
antithyroid and antiadrenergic effects▫May take 4-8 weeks after discharge
•Aggressively treat infection, underlying precipitants
Prognosis
•Thyroid storm is usually fatal unless treated▫Overall mortality 10-20%, some report 75%▫The precipitating factor is usually the
underlying COD•With early diagnosis and prompt
treatment, prognosis is good.
Patient Education
•Stress the importance of medication adherence.
•Stress the importance of medication adherence.
•Explain the possible side effects of treatment.▫Antithyroid – liver failure, agranulocytosis▫Anti-adrenergic – hypotension,
dermatologic▫Corticosteroids – cushingoid disease, DM
Medicolegalities• Because of variable presentation, thyroid
storm may be missed in patients who present obtunded or comatose.
• Apathetic thyrotoxicosis in the elderly▫Protracted duration of symptoms▫Weight loss▫Cardiovascular abnormalities (common)▫Ocular findings (less common)
• Consider thyrotoxicosis in patients with acute behavioural changes referred for psych evaluation.
Grave’s Disease
•60–80% of thyrotoxicosis.
•~2% of women but is 1/10 as frequent in
men. •rarely begins before adolescence and typically
occurs between 20 and 50 years of age, but it also occurs in the elderly.
Pathogenesis
•ENVIRONMENTAL and GENETIC ▫ polymorphisms in HLA-DR, CTLA-4, and PTPN22 (a T cell
regulatory gene.
• SMOKING is a minor risk factor for Graves' disease and a major risk factor for the development of ophthalmopathy.
• Sudden increases in iodine intake may precipitate Graves'
disease, and there is a 3x increase in the
occurrence of Graves' disease in the postpartum period.
• The hyperthyroidism of Graves' disease is caused by
TSI that are synthesized in the thyroid gland as
well as in bone marrow and lymph nodes.
• Other thyroid autoimmune responses, similar to those in autoimmune hypothyroidism occur concurrently in patients with Graves' disease.
• In particular, TPO antibodies occur in up to 80% of cases and serve as a readily measurable marker of autoimmunity. In the long term, spontaneous autoimmune hypothyroidism may develop in up to 15% of Graves' patients.
•Cytokines appear to play a major role in thyroid-associated
ophthalmopathy.
• Infiltration of the extraocular muscles by activated T cells; the release of cytokines such as IFN-, TNF, and IL-1 results in
fibroblast activation and increased synthesis of
glycosaminoglycans that trap water, thereby leading to characteristic muscle swelling.
• Late in the disease, there is IRREVERSIBLE FIBROSIS.
•TSH-R MAY BE A SHARED AUTOANTIGEN that is expressed in the orbit.
• INCREASED FAT is an additional cause of retrobulbar tissue
expansion. The INCREASE IN INTRAORBITAL PRESSURE can lead to proptosis, diplopia, and optic neuropathy
Clinical Manifestations
•ophthalmopathy and dermopathy specific for Graves' disease
Opthalmopathy Grading
0 = No signs or symptoms 1 = Only signs (lid retraction or lag), no
symptoms 2 = Soft tissue involvement (periorbital
edema) 3 = Proptosis (>22 mm) 4 = Extraocular muscle involvement
(diplopia) 5 = Corneal involvement 6 = Sight loss
In the elderly, features of thyrotoxicosis may be subtle or masked, and patients may
present mainly with fatigue and weight loss,
a condition known as APATHETIC THYROTOXICOSIS.
•UNEXPLAINED WEIGHT LOSS• WEIGHT GAIN OCCURS IN 5%
•HYPERACTIVITY, NERVOUSNESS, AND IRRITABILITY• SENSE OF EASY FATIGABILITY • INSOMNIA AND IMPAIRED CONCENTRATION
•FINE TREMOR •HYPERREFLEXIA, MUSCLE WASTING, PROXIMAL MYOPATHY
WITHOUT FASCICULATION• HYPOKALEMIC PERIODIC PARALYSIS (ASIAN MALES WITH
THYROTOXICOSIS)
•SINUS TACHYCARDIA, OFTEN ASSOCIATED WITH PALPITATIONS, OCCASIONALLY CAUSED BY SUPRAVENTRICULAR TACHYCARDIA
• HIGH CARDIAC OUTPUT PRODUCES A BOUNDING PULSE, WIDENED PULSE PRESSURE, AND AN AORTIC SYSTOLIC MURMUR
•ATRIAL FIBRILLATION IS MORE COMMON IN PATIENTS >50 YEARS
•WARM AND MOIST SKIN •SWEATING AND HEAT INTOLERANCE, • PALMAR ERYTHEMA, ONYCHOLYSIS• PRURITUS, URTICARIA, AND DIFFUSE ALOPECIA IN 40%• HAIR TEXTURE MAY BECOME FINE, AND A DIFFUSE ALOPECIA OCCURS IN UP TO
40%
• GI TRANSIT TIME IS DECREASEDINCREASED STOOL FREQUENCY, OFTEN WITH DIARRHEA AND OCCASIONALLY MILD STEATORRHEA
• OLIGOMENORRHEA OR AMENORRHEA
• IMPAIRED SEXUAL FUNCTION, RARELY, GYNECOMASTIA.
•OSTEOPENIA IN LONG-STANDING THYROTOXICOSIS• MILD HYPERCALCEMIA OCCURS IN UP TO 20% OF PATIENTS, BUT
HYPERCALCIURIA IS MORE COMMON SMALL INCREASE IN FRACTURE RATE IN PATIENTS WITH A PREVIOUS HISTORY OF THYROTOXICOSIS.
• GOITER 2X ITS NORMAL SIZE, FIRM, THRILL OR BRUIT• LID RETRACTION
•GRAVES' OPHTHALMOPATHY OR THYROID-ASSOCIATED OPHTHALMOPATHY▫occurs in the absence of Graves' disease in
10% of patients.
•Onset occurs within THE YEAR BEFORE OR AFTER the diagnosis of
thyrotoxicosis in 75% of patients.
THYROID DERMOPATHY occurs
in <5% of patients with Graves' disease
most frequent over the anterior and lateral aspects of the lower leg
(pretibial myxedema)
THYROID ACROPACHY in
<1% of patients with Graves' disease
MANAGEMENT
Treatment of Graves’ Disease
Hegedus, L. 2009. Treatment of Graves’ Hyperthyroidism: Evidence-Based and Emerging Modalities. Endocrinol Metab Clin N Am 38: 355-371.
Treatment Choices
•Antithyroid Drugs•Radioactive Iodine•Surgery
Antithyroid Drugs
PTU Methimazole
Carbimazole
Antithyroid Drug RegimensThe starting dose of antithyroid drugs can
be gradually reduced
(TITRATION REGIMEN) as thyrotoxicosis improves.
High doses may be given combined with levothyroxine supplementation
(BLOCK-REPLACE REGIMEN) to avoid drug-induced hypothyroidism.
Other Drugs
•Beta-adrenergic Antagonist Drugs•Glucocorticoids•Inorganic iodide•Iodine-containing compounds•Potassium perchlorate•Lithium carbonate•Novel Immunomodulatory agents
(rituximab)
Radioiodine Treatment
•causes progressive destruction of thyroid cells
•can be used as initial treatment or for relapses after a trial of antithyroid drugs
•Small risk of thyrotoxic crisis, hence the need for antithyroid drugs prior to radioiodine treatment▫Carbimazole or methimazole - stopped at
least 3 days before radioiodine administration
▫Propylthiouracil - has a prolonged radioprotective effect
Radioiodine Treatment
• 131I dosage range between 185 MBq (5 mCi) to 555 MBq (15 mCi)
•Tendency to relapse▫thyroid ablation vs. euthyroidism
•Safety precautions▫Avoid contact with children and pregnant
women•Risk of hypothyroidism•Contraindicated in pregnancy and
breastfeeding mothers
Radioiodine Treatment
•Severe ophthalmopathy requires caution▫prednisone, 40 mg/d, at the time of
radioiodine treatment, tapered over 2–3 months to prevent exacerbation of ophthalmopathy
Surgical
•option for patients who relapse after antithyroid drugs and prefer this treatment to radioiodine
•careful control of thyrotoxicosis with antithyroid drugs, followed by potassium iodide (3 drops SSKI orally TID needed prior to surgery
•complications▫bleeding, laryngeal edema,
hypoparathyroidism, and damage to the recurrent laryngeal nerves
•Thank you
3/11/102AM
DEMS DNTG in storm with CHF FC II-IIII with AF in RVRt/c CAP-MR
PTU 50 mg/tab 12 tabs now then 1 tab TID (2AM)Propanolol 40mg/tab now then40 mg tab ODDigoxin 0.25 mg IV nowFurosemide 40 mg IV (2:30AM)SSKI 5 drops q6, 1 hr post PTU (3:30AM)Dexamethasone 2 mg IV q6 (4:30AM)Hooked 4 lpm
4:50 AM
POD DTG in storm Thyrotoxic Heart Disease in CHF FC III with AF in RVRt/c CPC of the livers/p IUD insertion (2000)
PTU 50 mg/tab 2 tab q6Propanolol 10mg/tab TIDDigoxin 0.25 mg/tab ODSSKI 5 drops q6, 1 hr post PTU Dexamethasone 2 mg IV q6Paracetamol 500mg/tab for T 38.5O2 via NC at 2-4lpm, hook to CM
6 AM Gen Med DTG in storm Thyrotoxic Heart Disease in CHF FC III with AF in RVRt/c CPC of the livers/p IUD insertion (2000)
Increased PTU to 4 tabs q6Increased propanolol to 2 tabs TID
• 3/11/10 Alb 22 low alk phos 94 AST 61 high ALT 42 Ca 1.86 low Mg 0.82
• Gluc 5.6 Crea 131 high Na 133 low K 3.2 low Cl 104• PT 11.3/22.4/0.35/2.15• APTT 35.8/52.8• U/A dy h 1.015 6 trace sug neg prot 0-1 RBC 1-3 WBC 0-1
hyaline casts 0-1 waxy c occ epith cells neg crystals 1+ bact occ mt
Bilirubin 3+ trace ketone CBC 10.1 3.6 101 0.302 83.7 28.1 336 15.9 2010.7 0.15 0.14 0.01 03/13BUN 21.69 Crea 138 BCR 38.82 (prerenal azotemia)Mg 0.70 Na 137 K 2.7
• Decrease in edema• Decrease in resting dyspnea• Decrease in abdominal distension• No hyperdefecation• No agitation• No palpitations• With easy fatigability
• Awake afebrile not in distress• Stable VS no pallor AP, irreg irreg no murmur• Intact traubes (+) fluid wave, succusion splash, shifting dullness, bipedal edema
• A> Grave’s disease not in storm• t/c TTHD with CHF FC II in AF in CVR• t/c TTLD• Home meds
1. Furo 20 mg 1 tab bid 2. Spiro 25mg 1 tab od3. Propanolol 10 mg tid4. PTU 50 mg 2 tabs tid5. Vit d + CaCO3 1 tab bid6. Kalium durule tid x 3 d
Medication
•PTU 600 mg loading dose then 200-300 mg q6h
•SSKI 5 drops q6h 1hr after PTU •Propanolol 40-60 mg PO q4h or 2 mg IV
q4h•Dexamethasone 2 mg q6h