Iodine + tyrosine (protein for amin acid) = Thyroid hormone

- T3, T4, calcitonin

Stimulation:

Hypothalamus (TRH; thyrotropin stimulating hormone) -> Pituitary gland (Thyroid stimulating
hormone) -> Endocrine gland (Thyroid; T3 T4, calcitonin)

HORMONES: (cell respiration in all body parts and brain; responsible for metabolic activities)

THYROID GLAND

1. T4 thyroxine
- Maintains body’s metabolism on a steady state
- Weak hormone
2. T3 triiodothyronine
- Potent compared to T4
- T3 increases then T4 increases
3. Calcitonin
- Secreted if plasma calcium is high in the blood
- Increases deposition of calcium in the bones (reabsorption)
- Bone resorption – melts down bone then goes to the blood (high serum calcium)

Dx

1. Physical Examination
o Symmetry, swelling, redness, pain, loss of function,
2. TSH level
o Single best screening
o Normal is 0.4 – 6.5
o TSH low (high thyroid hormone) = Hyper
o TSH high (low thyroid hormone) = Hypo
3. Free T4
o Normal is 0.9 – 1.7 mg/dL or 11.5 – 21.8 mol/L
o Thyroid binding globulin (target organ is heart)
 Normal is 25 to 35%
 T3 resin reuptake (>35 or <25)
4. Serum T3 and T4
o In blood
o T3 (70 – 220 mg/dL
o T4 (4.5 – 11.5 mg/dL
 5. T3 resin uptake test
o Indirect measurement of thyroid hormone
6. Thyroid antibodies
o Chronic autoimmune ant microsomal diseases
o Hashimoto’s disease
o Grave’s disease – TRAB (Thyroid Receptor Antibodies – imitates TSH function)
hyperthyroidism
o Lupus erythematosus – inflammation of all organs, RA
7. Radioactive iodine uptake
8. Fine needle aspiration biopsy – confirmatory for cancer
9. Scan, UTC, MRI, CT scan

HYPERTHYROIDISM

- Female, 20 – 40 y/o
- Stress, infection in thyroid (thyroiditis; grave’s disease), ingestion of thyroid hormone w/o
prescription (self-medication)
- Idiopathic
- “Everything is accelerated
- Increase in metabolism

S/SX
o Exophthalmos (stare) – remove mirrors, eye drops
o Heat intolerance
o Hyperhydrosis (soft, warm, moist skin)
o Increased appetite; decreased weight gain
o Super sensitive to epinephrine, catecholamines (increase in RR, HR)
o Increased GIT (diarrhea)
o Amenorrhea
o Decreased libido
o Mucopolysaccharides on legs and face (deposits of skin)
o Tingling, weakness, fatigue

DX

o Large thyroid
o Positive bruit
o Soft pulsation
o Increased FT4, T4, T3
o T3 resin uptake >35%
 MX

o Radioactive isotopes – ingestion of RAI to destroy parts of the thyroid (used mostly in
elderlies, multimodule, goiter, thyrotoxicosis)
 Sore throat, neck pain, metallic taste
 Contraindicated to pregnant and breastfeeding women
 3 to 4 weeks til effect
o Antithyroid medications
 Methimazole, PTU (propylthiouracil)
 Prescription of propranolol
Cx
 Agranulocytosis (decrease of WBC) report immediately to the doctor
 Allergies
o Thyroidectomy
 Can cause hypo parathyroid
 Used for patients who have allergies to RAI and antithyroid meds
 Very large goiter
 Pregnant women
Emergency cases – giving of iodine compounds (rapid but short termed)
 Decreases vascularity and thyroid hormones before operation
PRE OP
Potassium iodide
Lugul’s solution
SSKI (saturated solution potassium iodide)

Nsg Mx

o Avoid coffee, cola, tea

o High calorie, CHON diet
o Eat alone (eating of large meals)
o Propranolol

HYPOTHYROIDISM

- Female, 30 – 60 y/o, Hashimoto’s disease (genetic), aging – atrophy

- Surgery, radioactive isotope, radiation (past dx of hyperthyroidism), over medication, too much
ingestion of iodine or low iodine consumption, amyloidosis (CHON), scleroderma (hardening of
skin tissue)
- “Everything is in slow motion”

S/SX
o Hair loss, brittle hair, and nails
o Mask like face
o Cold intolerance
 o Hypohydrosis – dry skin
o Decreased appetite; increased weight gain
o Decreased BP and HR
o Decreased GIT (constipation) – increase FI
o Metrorrhagia
o Decreased libido
o Tingling, weakness, fatigue

DX

o Decreased FT4, T3, T4

o Increased FSH
o T3 resin uptake <35%

Nrg Mx

o Synthetic thyroid hormone (levothyroxine)

o Manage cholesterol / anti-cholesterol medications
o Assess drug interactions
o Myxedema coma – no warm compress (increases O2 demand)
o Monitor fluids, O2, IO, v/s
o Thyroid medications

CRISIS:

(Hyperthyroidism)

Thyroid storm / thyrotoxicosis

- Ooverwhelming presence of T3 and T4

- Due to stress, dental sx, infection, tooth extraction, injury, no mx of current situation
- Increased BP, HR, temp
- Risk for hypertensive crisis and stroke
- Dysrhythmia – arrest
- Heart failure
- Hypertrophy of heart (due to excessive use / pumping action)

Hyperthyroid Periodic Paralysis (HPP)

 - Males, Asian
- Decreased potassium (hypokalemia)

Hypothyroidism

Myxedema coma

- Decreased BP and HR, temp

- Cardiac collapse
- Respiratory collapse
- Hypothermia
- Same causes with thyroid storm + coma
- Giving of sedatives may cause coma
PARATHYROID

- Phosphorus and calcium metabolism

- Increase in parat hormone -> increases absorption of calcium -> Increases serum calcium
- GIT increase absorption from food
- Kidneys decreases excretion of calcium
- Bone resorption to increase serum calcium in the blood
- Increase in serum calcium = decrease in phosphorus (inverse relationship)
- Calcitonin – increases reabsorption (return to the bone)

HYPERPARATHYROIDISM

- Women, 60 – 70 y/o
- Secondary to chronic renal failure (cannot excrete phosphorus)
- Idiopathic

S/SX

o Increase in calcium
o Apathy, fatigue, weakness
o Increased deposition of calcium = increased risk for renal stones = increased risk for
obstruction and pyelonephritis = renal failure
o Fever, hematuria, pain dysuria, flank pain
o Increased bone destruction, brittle bones, pathologic fracture
o Constipation, increase risk for ulcers

Mx

o Hydrate patient
o Cranberry juice
o Avoid dehydration
o Observe signs of renal calculi (hematuria, dysuria, abd pain, flank pain)
o Mobility (increases bone absorption)
o Decrease calcium, increase phosphorus, and protein in diet
o Anti-ulcer medications
o Antispasmodic (renal calculi)
o Acute hyper calcemic crisis – hydrate, phosphate therapy, diuretic
o Cytotoxic medications – mithramycin, calcitonin, etidronate, pamidronate
o Dialysis

HYPOPARATHYROIDISM

- unknown atrophy
- decreased blood supply
- Sx, radiation
- Idiopathic

S/SX

o Decreased absorption of calcium

o Increased excretion of calcium
o No additional calcium in blood
o Irritability of nerve
o Muscle cramps, tingling, pins and needles, tremors, uncoordinated movements,
numbness
o Dysphagia, loss of appetite, loss of weight
o Tetany – spasm in bronchospasm and laryngeal spasm
 Carpopedal spasm
 Chvostek’s and trousseau’s sign
 BEDSIDE – LARYNGOSCOPE OR INTUBATION SET AND CALCIUM GLUCONATE

DX
1. Check serum calcium level
2. Level of parath hormone
3. Assess any bone changes
4. Double antibody parath test

Mx

o Raise calcium
o Possibly tetany after sx give calcium gluconate and anti-seizure medications
o Increase parath hormone (ask for allergy)
o Increase calcium (don’t give milk, eggyolk, spinach… since it is high in phosphorus)
o Give calcium salts, aluminum hydroxide, aluminum carbonate, gelosil, amphogel,
o Vitamin D -> increase calcium absorption in GIT
Adrenal gland

- Medulla (inside); cortex (outside)

- Kidney

Stimulation

- From the hypothalamus; corticotropin releasing hormone -> adrenocorticotropin hormone ->

Medulla

- Epinephrine and norepinephrine (adrenaline rush; fight or flight response)

- Cardiac, respiration, brain, musculoskeletal
Norepinephrine
o Responsible for release of fatty acids
o Increases metabolic rate
o Increases sugar

Epinephrine

o Decreases blood flow GIT, reproductive, and urologic

o Increases blood flow to major systems
o Increases heart, respiration, musculoskeletal

Cortex

Glucocorticoid (from body); corticosteroids (from medications) -> hydrocortisone -> increase
sugar
o Overstimulation causes DM, osteoporosis, peptic ulcer disease
o Excessive exogeneous (outside source) results to atrophy can cause adrenal insufficiency

Androgens (sex hormones)

o Excessive = adrenogenital syndrome (hirsutism, gynecomastia…)

o Low dose = insignificant

Mineralocorticoid (aldosterone)

o Kidney receptor vasa recta (detects if BP is low)

 Stimulated if low BP, kidney then releases renin, liver releases angiotensin, add
together becomes angiotensin 1, angiotensin 1 +angiotensin converting enzyme
(lungs) then becomes angiotensin 2. A2 stimulates adrenal cortex to produce
 aldosterone which regulates fluids; decreases sodium excretion and increases
sodium absorption (RAAS SYSTEM)

ANDRENAL INSUFFICIENCIES

Hyper (Cushing’s disease)

- 20 – 40 y/o females
- Increase exogenous source, pituitary tumors (Cushing’s syndrome), hyperplasia, ectopic ACTH
malignancy, bronchogenic Ca
- Idiopathic

S/SX

Medulla N/E

o Increase BP, HR, sugar

Cortex

Glucocorticoid

o Increase sugar -> DM

o Slow wound healing
o Increase risk for infection
o Weight gain
Sex hormones
o Increase virilization, hirsutism, breast atrophy, gynecomastia, no menses, clitoral
enlargement, decrease libido, erectile dysfunction
Mineralocorticoid
o Increase sodium, water (causes truncal obesity, moon face, and buffalo hump, thin
extremities), BP, HR, weight gain

CX

- Hypertension, DM

DX

- Increase urine excretion of sugar (sugar cortisol), increased sugar

- Overnight dexamethasone suppression test (outpatient -1mg oral steroid at 11pm; 8am – serum
cortisol.
o Less than 5 mg/dL (normal)
o Assess pts medications: antiseizure, estrogen, rifampicin (affects test result)
- 24 hr urine free cortisol levels
o Start with empty bladder, end with empty bladder
- Plasma ACTH radio immunoassay
 - MRI, CT, UTZ
- ACTH administration test (metyrapone)

MX

- Transsphenoidal hypophysectomy (pituitary surgery)

Adrenalectomy
o Can cause adrenal insufficiency; steroid therapy for first 12 hours
- Radiation
- Taper down exogenous steroids (allergies, transplant surgeries)
- Adrenal enzyme inhibitor (aminoglutethimide, ketoconazole, mitotane)
- If 2 glands are removed, lifetime medication
- Decrease sodium and increase potassium diet
- Monitor glucose, IO, Na and K imbalance, daily weight, medical bracelet

Hypo (Addison’s disease)

- Autoimmune problems, idiopathic atrophy,

- Surgical removal of adrenal gland, infection, TB, histoplasmosis
- Idiopathic
Adrenal insufficiency
o Therapeutic cortisol management for 2 – 4 weeks
o Mx is to taper down

S/SX

Medulla N/E

o Decrease BP, HR, sugar

Cortex
o Decrease sugar
o Weight loss

Sex hormones

o insignificant

mineralocorticoid

o decrease sodium increase in potassium, decrease water, BP, HR

o as compensatory mechanisms ACTH is increase although the hormone would still
remain the same, ACTH then affects melanin stimulating hormone wherein this makes
the patient’s skin bronze

CX

- Addisonian crisis
 o Cardiac collapse

DX

- Low sugar, sugar cortisol, high potassium

- Overnight dexamethasone suppression test
- 24 hr urine free cortisol levels
- Plasma ACTH radio immunoassay
- MRI, CT, UTZ
- ACTH administration test (metyrapone)

MX

- Steroid IV (prednisone,
- D5 IVF
- Vasopressors amine (increase BP)
- Antibiotics
- Raise legs to increase BP
- Gradual ambulation
- Monitor dehydration, V/S
- Increase sodium and decrease potassium diet
- If crisis occurs = avoid stress, IV glucose, steroid IV, no exertion

VAGUE S/SX for both

- apathy
- abdominal pain
- anorexia
- bruising
- depression
- thin and fragile skin (edema)