HYPERTHYROIDISM & HYPOTHYROIDISM

LEARNING OBJECTIVES:

KNOWLEDGE: - Students should be able to describe:

1. presenting symptoms and signs of hyperthyroidism and hypothyroidism.
2. presenting symptoms and signs of thyroid storm and myxedema coma.
3. major causes of morbidity and mortality in untreated hyperthyroidism and hypothyroidism (bone disease; cardiovascular disease)
4. pathogenesis of hyperthyroidism and hypothyroidism.
5. history and physical examination findings in hyperthyroidism and hypothyroidism.
6. laboratory tests needed to diagnose hyperthyroidism and hypothyroidism including:        
   • T3, T4, TSH
   • TBG
   • 24-hour uptake
   • Thyroid scan
   • Free T4
   • Thyroid autoantibodies especially thyroid peroxidase antibodies
7. goals of treatment of thyroid disease (i.e., achieving clinical and chemical euthyroidism; preventing thyroid storm and myxedema coma).
8. management strategies for thyroid storm and myxedema coma states.

PATIENT CARE SKILLS:

1. History-Taking Skills:   Students should be able to obtain, document and present an age-appropriate medical history that differentiates among etiologies of disease including:
   • weight gain or loss, change in temperature tolerance or bowel habits, weakness, fatigue, recent skin or eye changes, medication history (e.g., iodine exposure, corticosteroids, medication compliance), family history of thyroid     disease, and travel history (Trinobel)
   • disease complications (e.g., cardiac symptoms)
2. Physical Exam Skills:   Students should be able to perform a physical examination on patients with hyperthyroidism or hypothyroidism to establish the diagnosis and severity of disease focusing on:
   • altered mental state, stupor, coma, slowed respirations, and skin examination for thyroid dermopathy, thyroid oculopathy, neurologic exam for both muscle strength and reflexes
3. Differential Diagnosis:   Generate a differential diagnosis recognizing specific history and physical exam findings to diagnose hyperthyroidism or hypothyroidism.   Also, exclude other causes of thyroid disease
4. Laboratory Interpretation:   Students should be able to recommend when to order diagnostic and laboratory tests, both prior to and after initiating treatment, based on the differential diagnosis.   Laboratory and diagnostic tests may include:
   • TSH
   • T3, T4
   • TBG
   • Free T4
   • Thyroid autoantibodies especially thyroid peroxidase antibodies.  
   • 24 ° uptake/scan, if appropriate
5. Communications Skills:   Students should be able to explain the results of the evaluation to the patient.
6. Management Skills:   Students should be able to:
   • determine appropriate treatment of hyperthyroidism and hypothyroidism
   • determine when to involve an endocrinologist in the care of a thyroid patient
   • access and utilize appropriate information systems and resources to help delineate issues related to thyroid (i.e., American Thyroid Association)

ATTITUDES AND PROFESSIONAL BEHAVIORS:    Students should be able to:

1. appreciate the impact of thyroid disease on the individual and the family
2. consider the individual's socioeconomic background when treating the patient

HYPERTHYROIDISM READINGS :

1. Jameson L and Weetman A.    “Diseases of The Thyroid Gland” from Harrison's Principles of Internal Medicine .   15th edition, NY, McGraw-Hill, 2001: pp 2060-84.

HYPOTHYROIDISM READINGS :

1. Jameson L and Weetman A.    “Diseases of The Thyroid Gland” from Harrison's Principles of Internal Medicine .   15th edition, NY, McGraw-Hill, 2001: pp 2060-84.