1- Drugs (amiodarone – lithium)
2- Autoimmune (e.g. Hashimoto thyroiditis)
3- Post surgical ttt of thyrotoxicosis
4- Post radiation ttt of thyrotoxicosis
5- Post – partum thyroiditis: transient hyperthyroid euthyroid
hypothyroditis then return back to euthyroid.
- TFT ↓FT3, ↓FT4, ↑TSH 1ry
↓FT3, ↓FT4, ↓TSH 2ry
- Thyroid peroxidase antibodies
- Anti-thyroglobulin antibodies
- Radio isotope scanning uptake
- US: multinodular + cystic + solid
o Cold malignant biopsy
o hot benign
- Need to give thyroxin gradually because the heart in hypothyroidism is
functioning slowly, so if we give ↑thyroxin this would ↑ metabolic demand.
The heart cannot cooperate with this & might infarct.
- 0.5 μ.g thyroxin ( as starting point then gradually ↑ for life as replacement )
& follow her up within 6-8 weeks to see the stabilization of thyroid level
because it is half life is ( 6-8 ) weeks .
** In elderly start with low dose WHY??
↓metabolic rate can go in infarction
- Better not to operate on hypothyroid patient till 3 months. If it is an
emergency operation order it. She will not die from hypothyroidism but from
1- post–partum thyroditis
Radiation induced thyroditis
Drugs ( amiodaron )
2- sub acute thyroditis " De Quevare "
4- thyrotoxic gravidarum.
No ttt for these only symptomatic ttt
1- Beta blocker
1- TFT : antibodies Graves disease
↑↑T3 & T4
2- Thyroid ultrasound diffuse enlargement Graves
3- Cold or hot
4- ECG atrial fibrillation
5- CXR retrosternal goiter
HOW TO DIFFERENTIATE BETWEEN THE DIAGNOSIS OF GRAVES
DISEASE & SUB-ACUTE THYRODITIS?
Isotope scanning ↑ uptake Graves
↓uptake sub acute thyroiditis
Surgery with thyrotoxicosis
Potassium iodine inhibit conversion & release ( 5 ml Tds ) with following
Beta blocker about 3-4 days before operation.
+ anti-thyroid but it will take long time
dexamethsone inhibit conversion of T3 to T4.
TTT of Grave's disease:
1- Radioactive iodine (no increased risk of malignancy & need only one
setting for adjusted dose) method of choice better than anti-thyroid &
surgery … WHY?
At last 1.5 – 2 years + ↑ recurrence
1- Low recurrence rate.
2- Better compliance.
3- Not needed to be taken for long duration.
- The only percussion is conception.
- Need to stop radiation by at least 2 months.
- Rare complication is inducing thyroiditis.
- Rare complication in Grave's with eye sign is aggravation
- Of the eye sign that why we start them on oral corticosteroid about 3-4
days before isotope radiation for 3-4 weeks ( 30 – 40 mg / day )
3- Neumercazole :
The most important side effect is neutropenia so warn the patient if they
develop any fever to come to ER & report that they are taking anti-thyroid
drug, stop medication & shift to other type.
After starting the patient on a big dose (35 -30 mg / day Neumercazole)
then, see him in 6-8 weeks & give her the maintenance dose.
If she gets pregnant: follow-up with her & adjust the dose according to her
TFT & continue normally on Neumercazole with no problem.
- Once level of TSH stabilized follow her up every 3-6 months by TSH, even if
N don't change the dose!!
- If a patient admits with ↓T4 but TSH is N that means she has poor
compliance تنسى تأخذ الحبوب بانتظام
So, we are emphasizing on compliance & NO dose change – with regular use
& thyroxin symptoms improve by 2-3 weeks.
Sub clinical hypothyroidism
↑ TSH + T3 / T4 ( N )
1- TSH > 10 Um / L
2- Family history with thyroid problem
3- Positive thyroid antibodies.
5- The patient is symptomatic.
This group will develop hypothyroidism later on and so, will need
Primary adrenal failure
Secondary failure to the axis
Causes of primary:
1- Most common: autoimmune
2-Infections: TB , meningococcal , HIV , fungal (histoplasmosis ,
3- Malignancy: tumor of adrenal or metastasis
4- Drugs: ketoconazol + metinapol ( used to test for Cushing's disease )
7- Infiltration by amyloidosis + heamochromatosis + Wilson's
Causes of secondary:
1- Sheehan syndrome post – partum hemorrhage
2- Any tumor compressing the pituitary
2- Nausea, vomiting
4- Hyper pigmentation (creases + press areas)
5- Postural hypotension
6- Vitiligo can be associated with Addison's
Organ specific disease ( autoimmune )
3- Pernicious anemia affecting parietal diseases
6- DM type I
7- Premature ovarian failure
Causes of DKA aggravating factor :
Medical dose of insulin
Infection (URTI ,UTI )
Trauma or surgery
New undiagnosed cases
Abdominal pain + vomiting because dilated stomach
Hyperventilation kussmaul breathing
# Normal anion gab acidosis (hypercholaridemia)
Anion gab = 140 – (Ch + HCO3 )
1) acetozolamide (carbonic anhydrate inhibitor [diuretics] ) used in benign
intracranial HTN (Pseudotumor cerebri (PTC))
2) Road Traffic Accident (RTA)
3) Severe diarrhea
4) Renal artery stenosis
# high anion gab acidosis
1) Fluid: 1/2 the amount of 24hours. Required in the 1st 4-6hrs
* Normal saline
2) Insulin: short acting insulin (lispro) = 0.14 /Kg (bolus) then 0.1/Kg as
infusion / hour
# monitoring blood sugar hourly & the dropping of the blood glucose
occur gradually in rate of 75-120 m mol/L
* IM 6-10 v/h * Iv 4-6 v/h
#5 unit I.V bolus # 6 unit I.V infusion
#check glucose hourly
If > 120 drop reduce by 2 unit
If < 75 drop increase by 1 unit
#Then monitoring blood glucose hourly & adjust accordingly
# Very rapid decrease of glucose –cerebral edema
3) Electrolytes: monitoring the ECG
 K+ :
@ 5.5 K+ no k+
@ 4.5 10 meqev/ 500 cc
@ 4.4 – 3 20 meqev / 500 cc
@ < 3 30 meqev /500 cc
Not concentrate K+ in 500 cc more than 40 & should given slowly over 2
Put in 1st hour because hyperkalemia
 ph+4 : usually corrected by it self unless who develop hypo
phosphatemia in form of muscle weakness give 20 m mol of phosphate &
 Acidosis & HCO3:
Only correct if H < 7 , HCO3 < 5 before correction & after correction < 10
Normal HCO3 (24 – 28), his HCO3 = 6 deficient = 24 – 6 = 13
Deficient x 1/6 body weight = 18 x 10 = 180
Give half of it only i.e. = 90 give it we are not aim to ideal level over 1/2 hour
Therapeutic output depends on the patients opinion & what he