treatment investigations signs symptoms Causes Hormone

1. Radioactive 1. T3,4 1. Thyroid face 1. Irritability 1. Graves’disease Thyroid

iodine (high) ,TSH 2. Tachycardia 2. Insomnia 2. Multinodular
(permanent) (low) 3. Systolic HTN 3. Anxiety goiter
hormone
2. Anti-thyroid (thyroditits) 4. Eye signs 4. Weight loss 3. Toxic adenoma overproducti
Drugs 2. Antibodies 5. Hand signs 5. Diarrhea 4. Thyroiditis on
(methimazol (graves) (tremors) 6. Palpitation 5. Drugs
e and  TSI 6. Proximal (in elderly)  Amiodarone
propylthiour (immunoglobulin muscle (arrhythmia)
 Lithium (anti-
acil in first  Antithyroglobul weakness phsycotic)
trimester of  antimicrosomal 7. In general  contrast material
pregnancy) 1. High RAIU Increase (iodone)
3. Surgery (radioactive sympathetic
4. Treatment of iodine uptak) activity
cause and 2. Thyroid US
complication 3. hypercalcemi
s a

1. Thyroxine T3,4,TSH 1. Facial 1. Cretinism 1. Primary Thyroid

2. Treatment of Thyroid scan appearance 2. Delayed  hashimoto
the cause Hypercholester 2. Bradycardia milestone thyroiditis hormone
and olemia 3. HTN 3. Cold
 iodine deficiency-
 RAI
deficiency
complication Hyponatremia 4. Xanthelasma intolerence  surgery
s (low sodioum) 5. Umblical 4. Tirdness,mus  Drugs (amiodarone)
Macrocytic hernia cle cramps 2. SECONDARY
Anemia 6. Buffy face 5. Constipation
6. Weight gain
Hyperthyroidism
Causes
• Graves disease
• Toxic adenoma
• Functioning multinodular goiter
• Early stage of viral thyroidits
• Excess iodine in contrast dye and expectorants
• Drugs such as amiodarone causing some form of
thyroiditis
• Thyroid hormone administration in some of weight
losing pills
Graves disease
• Autoimmune
• May be associated with other autoimmune
disorders such as type 1 diabetes
• Common in females
• Middle aged
Clinical picture
• Anxiety,insomnia,nervousness and heat intolerence,loss of
weight despite good appetite
• Stair look
• Pulse .tachycardia and AF
• Systolic hypertension
• Fever
• Eye signs such as frequent blinking, rim of sclera is evident,
lack of convergence ,ruler test and external ophthalmoplegia
• The gland is enlarged with bruis
• Pretibial myxedema
-
Pre tibial myxedema
investigations
• High T4,T3 and low TSH (SUPPRESSED )
• Increased radioiodine uptake
• Thyroid antibodies
• Investigations of the heart such as ECG and
echocardiography
• Hyperglycemia
 Treatment
• Treatment of the cause
• Antithyroid drugs such as methimazol and propaylthyouracil
specially in the first trimester of pregnancy
• Beta blockers
• Surgery in pregnancy
• Radioiodine is preferred first line treatment but stop
antithyroid drugs before treatment .Thyroid replacement is
then given
• Treatment of the complications such as thyrotoxic heart
disease
 Thyroid storm
• Severe case of hyperthyroidism due to very high level of
thyroid hormone
• Precipitating factors include stress, infection and surgery
• The clinical picture is the same as hyperthyroidism in
addition to hyperpyrexia and loss of consciousness
• Treatment include antithyroid drugs and iodine to
prevent release of the hormone
• Corticosteroids are also give to support adrenal gland
• Cold foments
 Hypothyroidism
• Caused by congenital enzyme defects in
thyroid hormone synthesis
• Radiation or surgery
• Central as part of panhypopitutarism
• Idiopathic
• Hashimoto’s thyroiditis
• Amiodarone side effects due to reduced
peripheral conversion of T4 into T3
 investigations
Different types of anemias
Hyponatremia
hypercholestrolemia
Low T4,T3 with high TSH in primary form and
reduced TSH in secondary forms
Investigations of the complications such chest x
ray, echo heart ,……
 Clinical picture Cont.
• Fatigue ,cold intolerance, constipation ,weight gain
• Apathetic yellow face, coarse hair, slow voice,
hoarsness,puffy with loss of outer third of eye brows,
xanthelasma and xanthomatosis
• Bradycardia and hypertension both systolic and diastolic
• Skin is dry cold and coarse
• Doughy sensation
• Abdominal distension with umbilical hernia due to
weakness of the abdominal muscles
• Pericardial, pleural effusion and ascites rich in cholesterol
 Treatment
• L Thyroxine
• In elderly gradual increase of the dose to
avoid precipitation of angina
• Treatment of ischemic heart disease
• Treatment of hypercholesterolemia
• Treatment of hypertension
 Thyroiditis
• Post viral with reduced uptake and high ESR
• Hashimoto’s with gradual lymphocytic
infiltration of the gland and high titers of
antimicrosomal antibodies ultimitly lead to
hypothyroidism
• Postpartum ,recurrent with normal ESR
• Ridle’s thyroiditis with fibrosis of the gland and
retroperitoneal structures
The mechanisms responsible for hypercalcemia in addison’s disease : the reduction in
calcium removal were decreased glomerular filtration and increased tubular calcium
reabsorption. Both renal factors were secondary to volume depletion and improved rapidly
during rehydration with saline infusion.

The mechanism by which hyperthyroidism causes hypercalcaemia is suggested by the

literature to be a direct effect of thyroid hormone primarily on bone metabolism. With
treatment of hyperthyroidism, there is a reversal of the metabolic abnormalities towards
normal

Hypercalcemia in sarcoidosis is due to the uncontrolled synthesis of 1,25-dihydroxyvitamin

D3 by macrophages. 1,25-dihydroxyvitamin D3 leads to an increased absorption of calcium
in the intestine and to an increased resorption of calcium in the bone.
Pheochromocytoma and associated hypercalcemia secondary to parathyroid hormone-
related protein secretion. The hypercalcemia was corrected by removal of
the pheochromocytoma.
Also pheochromocytoma may stimulate parathyroid gland to secrete parathormone
Hypercalcemia
Pathophysiology
• Since calcium blocks sodium channels and
inhibits depolarization (No action potential) of
nerve and muscle fibers, increased calcium
raises the threshold for depolarization.
• Weakness, hyporeflexia and fatigue
• Depression ,confusion and coma
• Constipation and paralytic ileus
• Hypercalcemia lead to nephrocalcinosis and
nephrogenic diabetes mellitus and hence
polyuria and dehydration ……so give fluids
• Don’t give loop diuretics except after
correction of dehydration by fluids
• Patients are dehydrated due to vomiting and
poluria
 Parathyroid disorders
• Adenoma
• Hyperplasia
• Carcinoma
• Neoplasia

• Tertiary hyperparathyroidism in renal failure

 Cancers PTrP
• Squamous cell carcinoma
• Lymphoma
• Multiple myeloma
• pheochromocytoma
 Inflammatory and Granulomatous diseases
( activate vitamin D)
• Sarcoidosis
• Tuberculosis
• Crohn’s disease
• Chronic fungal infections
 Congenital causes
• Isolated familial hyperparathyroidism
• Familial Hypocalciuric hypercalcemia
 Endocrinal causes of
hypercalcemia
• Thyrotoxicosis ( osteoclasts)
• Acromegaly
• Addison’s disease (reduced renal excretion of
calcium)
• Pheochromocytoma PTrH
• Zollinger elisson syndrome
• MEN type 1 and 2 A
Drug toxicity lead to hypercalcemia
• Vitamin D
• Vitamin A
• Lithium
• Thiazide diuretics
 Investigations
• Ionized calcium
• Phosphates is decreased
• Urine analysis, osmolarity and urinary calcium
• Parathormone hormone
• Imaging
• Kidney functions
• Hormonal assay
• Chest x ray
• Plasma protein electrophoresis
• ECG ( short QT )
 Treatment and Emergency
• Above 15mg/dl
• IV fluids and hydration
• Loop diuretics
• Calcitonin:blocks bone resorption and also increases urinary calcium excretion by inhibiting calcium
reabsorption by the

• Bisphosphonates:I nhibit osteoclastic bone resorption

• Dialysis
• Glucocorticoids :not effective in hyperparathyroidism .effective in
MM and lymphoma
• Surgery or surgical neck exploration
• Surgery is indicated specially below 50 years or with development
of renal stones, osteoporosis
hypocalcemia hypercalcemia
Hypoparathyroidism Hyperparathyroidsm Causes
Vitamin D deficiency Malignancy: metastasis or PTrP
Drugs: loop diuretics (parathormone related peptide)
Heriditary: hypocalciuria
Alkalosis Granulomas: sarcoid and TB
Low albumin (pseudo Drugs: thiazide,lithium,vitaminD
hypocalcemia) Immobilization
acidosis
CNS. Increases exitability of nerves CNS: confusion, drowsiness Clinical
GIT: nausea,vomiting,abdominal
pain,constipation
CARDIOVASCULAR: arrythmias RENAL: polyuria
CARDIOVASCULAR: arrythmias
Of the cause Of the cause INVESTIGATIONS
Calcium gluconate IV Rehydration Treatment
Loop diuretics (fusomide)
Calcitonin (decrease Ca+ in blood)
Bisphosphnate
Dialysis
Corticosteroids in some cases