Tag Archives: pance

Medical Musing of the Week: Hyperthyroidism

Overview

  • Excess Synthesis and secretion of thyroid hormone by the thyroid gland
  • Hyperthyroidism exists as Graves Disease, Toxic Multinodular Goiter, Toxic Adenoma and Subacute Thyroiditis
  • The MCC of hyperthyroidism is Graves Disease  (50-60%)
  • Increased FT4 
  • Increased T3 in Subacute Thyroiditis
  • TSH is suppressed 

Pathophysiology

  • TRH is produced in the Hypothalamus which then signals the Pituitary Gland to secrete TSH to the Thyroid Gland signaling T3 and T4 to be released to peripheral tissues (see picture below if you are a visual learner.  C/o Medscape)
  • When adequate levels of circulating T3 and T4 have been achieved in the normally functioning thyroid a negative feedback signal is sent to hypothalamus to temporarily halt TRH production (and begin reproducing when T3 and T4 levels are low in periphery) 
  • Iodide binds to thyroglobulin via peroxidase.  This results in monoiodotyrosine (MIT) and Diiodotyrosine–combining to form T3 + T4 which are then stored in the thyroid as preformed hormone (these were terms I haven’t seen since didactic year, hah!)

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Etiology & Risk Factors

  • Genetic predisposition
  • Additional Autoimmune diagnosis
  • Pregnancy (Use PTU not MTU)
  • Women > Men
  • 20-40’s
  • Amiodarone toxicity (rare)

Clinical Manifestations

History

  • Nervousness/Restlessness
  • Increased bowel movements
  • Anxiety
  • Palpitations
  • Weakness
  • Menstrual Irregularities 

Physical Exam

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Exopthalmos
  • Fine resting tremor
  • Warm skin/heat intolerance
  • Thinning hair
  • Increased reflexes
  • Onycholysis
  • Enlarged thyroid
  • Sinus tachycardia/PAC’s/A-Fib
  • Exopthalmos

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    Pre-tibial Myxedema
  • Upper eyelid retraction
  • Lid lag w/ downward gaze
  • Pretibial Myxedema

Diagnosis

  • The single most important test is TSH (will be decreased)
  • The severity of clinical manifestations does not necessarily correlate with TSH level
  • ELISA for Anti-TPO for Graves Disease
  • Free T4 and Total T3 levels
  • EKG if Sinus Tachycardia (may also want to check electrolytes) 

Treatment

  • Methimazole
    • Starting dose: 5-20mg Q8h
    • Once euthyroid 5-15mg QD
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • Propylthiouracil
    • Starting dose: 300-400mg/day divided Q8h
    • Once euthyroid 100-150mg Q8h
    • Preferred in pregnancy (MTU is safe after first trimester)
    • More potent–also blocks T4 -> T3
    • Inhibit coupling of iodotyrosines in thyroglobulin resulting in a gradual decrease in circulating hormone over 2-8 weeks
    • Monitor levels Q4 weeks when first starting treatment
  • MTU & PTU side effects:
    • Fever, Rash, Agranulocytosis, Aplastic Anemia, Hepatitis
  • Radioactive Iodine Ablation (most common and effective treatment)
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Radioactive Iodine Ablation in a patient with Graves Disease
  • Thyroidectomy (not frequently performed due to effectiveness of RAI ablation)
  • Symptom relief (Beta blockers)
    • In addition to treating the symptoms of tachycardia, tremor etc– beta blockers also decrease conversion of T3 to T4 (which I didn’t know before!

Complications 

  • Patients who go through RAI ablation or thyroidectomy are often left hypothyroid.
  • Thyroid Storm
    • Acute life threatening hypermetabolic state caused by excessive thyroid hormone
    • Fever, tachycardia, hypertension, diaphoresis, AMS
    • Cardiac manifestations and complications can range from sinus tachycardia to high-output cardiac failure and arrhythmias 
    • Treatment
      • Methimazole is first line
        • 20mg Q4-6 hours
      • Propanolol is first line Beta Blocker
        • 60-80mg Q6h or .5-2mg IV Q10 minutes for the first few hours
      • Glucocorticoids
      • Supportive Measures

 

Sources:

Current Medical Diagnosis & Treatment 2015
UpToDate
Medscape

Board Review Product Focus: Physician Assistant Study Guide

 

Physician Assistant Study Guide

By: National Physician Assistant Education

First, I would like to say that I love ALL of these products and if I were taking the boards I would definitely be purchasing from National Physician Assistant Education. They offer three products which include PANCE/PANRE Study Guide PDF, PANCE/PANRE Study Guide Paperback Book & PANCE/PANRE 2016: Online PA Board Review Program.

PANCE/PANRE Study Guide PDF

This is the most concise resource I’ve seen while still being able to maintain comprehension.  The readability of the product is wonderful, the PDF could not be better organized.  It is put together by organ system just as the PANCE/PANRE so you won’t miss a thing you need to be prepared for your exam.

Helpful Hint: Download to google drive on your iPad to have easy access on-the-go! (or whichever tablet of choice you may own :))

Access PANCE/PANRE Study Guide HERE.  Original price: $14.99.

Use “allthingspa15” for 15% off! 

Example of PDF presentation below:

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PANCE/PANRE Study Guide Paper Back Book

If you are old school like me and prefer having a physical book in front of you to jot down notes and make your own, this is a great option. What’s also wonderful about getting the paper back book is that you get a TON of bonus materials!  In addition to a printed version of the PDF, you also get access to the online PDF for quick on-the-go access, full length 300 question practice exam access, and a comprehensive review list.

Access the PANCE/PANRE Study Guide Paper Back Book HERE.

Use “allthingspa15” for 15% off

PANCE/PANRE 2016: Online PA Board Review Program

The whole she-bang. The online review program is honestly awesome.  It has everything you need to prepare and excel for the PANCE or PANRE. The whole program was developed through a website and App called Schoology so you can conveniently study whenever and wherever you want! The website, program and app are incredibly user friendly and well organized.  The content is beyond comprehensive.  Organized by organ system and the NCCPA blueprint. With each organ system you get the PDF, Audio review, several matching quizzes.

In total you get 2000+ practice questions, 10 hours of audio review, 100+ flash cards, 109 page PDF review, 13 progress quizzes and 5 full-length exams.  

For $199 this is an awesome deal.  I paid $400 for my Kaplan review course and ended up not even using it because I didn’t think it was worthwhile.  I would have much preferred the PANCE/PANRE Online PA Board Review Program.  

Access PANCE/PANRE Online PA Board Review Program HERE.

Use “allthingspa15” for 15% off

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