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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Initial management of a patient with very high serum calcium is to replace extracellular fluid
volume with 0.9% saline (3–6 L/d in first 24 hours), to restore the glomerular filtration rate,
and to promote calcium excretion.
After extracellular fluid volume is restored, furosemide intravenously 2–4× per day can be
given if there is evidence of fluid overload or heart failure develops. Close monitoring of fluid
balance and electrolytes should be done. Thiazides should be avoided because they impair
calcium excretion and increase serum calcium.
If hypercalcemia does not improve with fluids, alternative therapy used in emergency treatment
is calcitonin and bisphosphonates. Calcitonin is immediate-acting; it is used if there is
decreased CNS function. Pamidronate and other bisphosphonates require time to act, but the
effect is long-lasting. Zoledronic acid is most potent. The 2 most common agents used for the
treatment of hypercalcemia are zoledronic acid and pamidronate. Repetitive IV use of
bisphosphonates has been associated with a risk of developing osteonecrosis in the jaw.
Dialysis is used if the hypercalcemia is life-threatening.
Further Follow-up
One week later the patient is admitted to the hospital and has successful removal of a single
parathyroid adenoma. He is doing well after the surgery and is transferred to the surgical
wards. The nurse contacts you 12 hours after the surgery and tells you that the patient has
developed facial spasm. You immediately order a calcium level and find it to be 6.4 mg/dL.
What is the likely diagnosis, of the hypocalcemia and what would you do next? Likely
diagnosis is hungry bone syndrome; treatment of hypocalcemia is IV calcium
Final Diagnosis
Hypercalcemia secondary to parathyroid adenoma
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Case 4
Chief Complaint
“I feel tired all the time.”
History and Physical Examination
A 64-year-old woman comes to your office with complaints of feeling tired all the time
for the past 6 months. She was planning to visit you for a while, but has put it off until
now. She has gained about 8 pounds over the last 6 months. She does not feel like doing
much of anything. She complains of feeling cold and has been using heavy blankets even in
the summer. She is constipated, gets frequent headaches, and is experiencing severe
muscle cramps. The only good thing she has to report is that her anginal chest pains are
less frequent than they used to be. She had only 2 episodes of chest pain in the last 6
months, and none in the last 4 months. For her angina she was taking isosorbide dinitrate
and a beta-blocker. Her cardiologist had recommended coronary artery bypass graft after
cardiac catheterization showed more than 70% obstruction of the left main artery.
Today her BP is 150/100 mm Hg and pulse 50/min. Her skin is dry. There is no
thyromegaly. The deep tendon reflexes have a delayed relaxation phase. The rest of the
physical examination is unremarkable.
CCS NOTE
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The amount of physical examination performed is initially determined by the history.
Examine any area that the patient describes as symptomatic. You can always go back
and examine the patient further, such as looking at other organ systems.
Differential Diagnosis
Initial Management
Setting: outpatient work-up and treatment
Diagnostic/Therapeutic Plan
Test Results
Assessment
This elderly patient has typical symptoms of hypothyroidism. The weight gain, cold
intolerance, and the complaint of feeling tired all the time are highly suggestive of
hypothyroidism. The seemingly improving anginal history is not uncommon in hypothyroidism.
As the demand for oxygen by the myocardium is diminished, the angina “improves.” Dry skin
and a puffy face are signs of long-standing hypothyroidism. The diastolic hypertension and the
Hypothyroidism
1.
TSH
Free T4
TSH: 49 mU/mL (normal 0.1–5 mU/mL)
Free T4: 1.5 mg/mL (normal 5–12 mg/mL)
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delayed relaxation phase are classical signs of hypothyroidism. The laboratory tests are
diagnostic of primary hypothyroidism.
In the elderly patient, cognitive deficits are sometimes seen with hypothyroidism.
Primary hypothyroidism is the cause of hypothyroidism in >95% of cases and is usually a result
of chronic thyroiditis (Hashimoto’s disease), associated with antimicrosomal antibodies. Post-
ablative surgery or radioactive iodine, heritable biosynthetic defects, and iodine deficiency can
also lead to primary hypothyroidism. Drugs such as lithium and acetylsalicylic acid can elicit
primary hypothyroidism.
Suprathyroid causes of hypothyroidism include pituitary-induced hypothyroidism (secondary
hypothyroidism) or hypothalamic-induced hypothyroidism (tertiary hypothyroidism).
Further Management Plan
Discussion
In patients with hypothyroidism, it is preferable to get coronary artery bypass graft done before
correcting the thyroid dysfunction with levothyroxine. Retrospective studies have shown that
there is no need to correct hypothyroidism before coronary artery bypass graft. Correcting the
thyroid dysfunction with levothyroxine is not only unnecessary, but it is potentially dangerous.
T3 is not any safer in patients with coronary artery disease. Theoretically, it is more dangerous
than levothyroxine.
CCS NOTE
Consider bypass surgery before correcting thyroid dysfunction1.
Thyroxine replacement2.
435
Consultations can be requested at any point in the case simulation, but you will need to
provide a reason for the consultation in ≤10 words. The consultants do not tell you how
to manage the case; they arrive promptly but say almost nothing.
If patient had no history of angina, we would have simply started her on 25 mcgs of
levothyroxine and would have gradually increased the dose over several wks until she became
clinically and biochemically euthyroid. The presence of coronary artery disease makes this
situation more complex. Therefore, it is strongly recommended that hypothyroid patients that
require coronary artery bypass graft do undergo the surgery before starting levothyroxine. This
is compounded by the apprehension that starting levothyroxine in these patients is going to
increase their heart rate and may actually aggravate their angina and precipitate myocardial
infarction.
The normal function of the thyroid gland is directed toward the secretion of L-thyroxine (T4)
and triode-L-thyroxine (T3), which regulate metabolic processes. The main secretory hormone
of the thyroid is T4, and it is only the free, nonbound-to-protein fraction of T4 and T3 that
affects metabolism. This free hormone is less than 0.01% of the total. Over 99% of the total
hormones are bound to thyroid-binding globulin.
Laboratory tests to measure free T4 and free T3 are now more accessible and give a direct
measurement of the metabolic active percentage of the hormone. These are the measurements to
look for when assessing thyroid function.
Total T4 or T3 is not always accurate because it measures protein bound and unbound thyroid
hormones. Increased thyroid-binding globulin levels, and thus total T4 levels, are seen in
pregnancy and with the use of oral contraceptives (but free or active T4 level is normal).
Decreased thyroid-binding globulin levels, and thus total T4 levels, are also seen in nephrotic
syndrome and cirrhosis (but free or active T4 level is normal with the patient being euthyroid).
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Thyroid-stimulating hormone is probably the most useful test in the diagnosis of
hypothyroidism. It is the best screening test for both hyper- and hypothyroidism. Overall, if the
thyroid-stimulating hormone is normal then likely the patient is euthyroid.
Note: Always look at the thyroid-stimulating hormone first when assessing thyroid hormonal
function. It is also the best test to do when following treatment of thyroid diseases.
Final Diagnosis
Hypothyroidism
437
Case 5
Chief Complaint
Weight loss
History and Physical Examination
A 44-year-old woman comes to the office complaining of 15-lb weight loss over 3
months. She gives a history of feeling hot and sweaty, and of difficulty sleeping and easy
arousability. She also complains of muscle weakness, especially when she tries to climb
stairs. She admits to moving her bowels 2–3 times per day for the last 4 months. She has
also noticed that her hands tremble all the time and her heart is racing. She is afebrile,
blood pressure is 150/90 mm Hg, pulse 112/min, and respirations 16/min.
Upon physical examination she is thin and is very restless. She has a pronounced stare.
There is a diffusely enlarged thyroid without any bruit. A very fine tremor of both hands is
noted. She is unable to get up from a squatting position without assistance.
CCS NOTE
The amount of physical examination you choose to perform is based on what you might
consider as abnormal. You do not lose points if a test result is normal.
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Differential Diagnosis
Initial Management
Setting: outpatient work-up and treatment
Diagnostic/Therapeutic Plan
Test Results
Assessment
This patient has all the symptoms and signs of primary hyperthyroidism due to Grave’s disease.
Further Management Plan/Results
68% (normal: 25–35%) diffuse uptake
Treatment Plan
Grave’s disease1.
Toxic multinodular or nodular goiter2.
Subacute thyroiditis3.
Serum TSH
Serum free T4
TSH <0.1 mU/mL (normal 0.5–5 mU/mL)
Free T4 6 ng/dL (normal 0.8–2 ng/dL)
24-hour radioactive iodine uptake scan
Beta-blocker and antithyroid drugs (propylthiouracil or methimazole) initially, to suppress
439
Discussion
The treatment of choice during acute thyrotoxicosis is antithyroid medication and a beta-
blocker, to make the patient clinically euthyroid. Once the patient is less toxic, radioactive
iodine can be used for permanent resolution of hyperthyroidism.
If radioactive iodine is given during severe hyperthyroidism, there is the possibility of inducing
radiation thyroiditis and releasing more thyroxine in to the circulation, worsening her
condition. Surgery is not an option in the initial treatment of Grave’s disease; it is useful only
for patients who:
Radioactive iodine is the main therapeutic option for Grave’s disease.
In the United States, the most common cause of hyperthyroidism in young people is Grave’s
disease. Those with Grave’s disease have diffuse thyromegaly and may also have vascular
bruit on auscultation because of increased blood supply to the gland. Up to 70% of patients
with Grave’s have exophthalmos, which is not a feature of any other thyroid disease. The
presence of exophthalmos makes the diagnosis certain.
CCS NOTE
the hyperactive thyroid
After the patient is euthyroid, radioactive iodine ablation for permanent treatment
Have large goiters, causing tracheal compression
Have refused to take radioactive iodine
Are pregnant
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