Page 33 Complete Your CE Test Online - Click Here Teach patients and families to make sure that patients take good care of their skin, which is generally dry and flaky. Emphasize that special attention should be paid to boney prominences[5] . Make sure that patients and families are aware of the signs and symptoms of worsening hypothyroidism, myxedema, and myxedema coma and to seek immediate medical help if they occur[5,6] . Caution patients and families to report any infection or occurrence of other diseases and disorders since these problems can affect hypothyroidism and mediation effectiveness[5,6] . Patients may be concerned about weight gain and begin to diet or to use weight loss products without health care supervision. Warn patients that it is essential to have an adequate nutritional intake. Work with patients and families to plan a well-balanced, low calorie diet to help with appropriate weight loss. Remind them that excessive rapid weight loss may be a sign of hyperthyroidism and to report such an occurrence[5,6] . Constipation is common among patients suffering from hypothyroidism. To reduce and/or prevent constipation encourage adequate fluid intake and a diet high in fiber. Stool softeners may be prescribed, as well as cathartics, as needed[5,6] . Help patients and families access community resources available for support and education. Include reliable, accurate Internet sites as part of this education. Caution patients and families not to believe everything they may read on the Internet as it relates to hypothyroidism. Help patients and families to critique Internet sites for reliability and validity. Hyperthyroidism Janice is a 32-year-old fashion consultant. She majored in fashion design with a minor in marketing in college. Janice’s husband, Dennis, is a business major, and it has been their dream to start their own business, establishing an exclusive upscale fashion boutique. Dennis’ parents are prominent members of the community and have agreed to invest in this business venture with the condition that his mother also works in the boutique “to keep an eye on things.” Initially things go well, but as time goes on Janice feels increasingly stressed. Her mother-in-law is constantly criticizing Janice’s decisions and tells her that “my friends will never come here unless you make this a really exclusive establishment.” Dennis is sympathetic but tells Janice that they must be patient until they earn enough money to buy his parents out of their share of the business. Janice begins to loss a considerable amount of weight despite having an increased appetite. She complains of feeling “jittery” and that her “heart pounds every time I have to go to work.” Janice also develops an extreme intolerance to heat. She and Dennis attribute these symptoms to stress. One cold winter afternoon, after listening to another round of her mother-in-law’s criticism, Janice states that she simply can’t stand how hot it is in the boutique. She goes outside and, despite the cold and significant snowfall, stands on the sidewalk in her sleeveless dress in an attempt to become more comfortable. Dennis, summoned from the office by his mother, finds Janice and insists that he take her to see their family physician at once. After listening to Janice’s recent history and conducting a few diagnostic tests, the physician diagnoses Janice with Graves’disease, a form of hyperthyroidism. Hyperthyroidism (also referred to as thyrotoxicosis or Graves’ disease) is a metabolic imbalance characterized by excessive amounts of thyroid hormone in the bloodstream[5,6] . Fortunately, with treatment, most patients lead normal lives[5] . Incidence, etiology, and pathophysiology Hyperthyroidism is more common in women than in men and affects about 2% of the female population[6] . A number of factors can increase the risk for development of hyperthyroidism. These include[5,11,16] : ● ● Family history: It is believed that genetic factors can make people more vulnerable to the disease. There is a marked increased incidence of the disease in monozygotic twins. ● ● Gender: The disease is more prevalent among women. ● ● Age: Most patients are over the age of 40. Only 5% of patients with hyperthyroidism are younger than 15 years of age. The incidence of Graves’ disease, however, is highest between the ages of 30 and 40. ● ● Coexistence of other autoimmune disorders: People with other autoimmune disorders such as type 1 diabetes or rheumatoid arthritis are at increased risk for the development of hyperthyroidism. ● ● Smoking: Cigarette smoking can increase risk for hyperthyroidism. ● ● Pregnancy: Women who are pregnant or who have recently given birth are at increased risk, especially if they also have genetic predisposition to the disease. ● ● Stress: Both physical and emotional stress can trigger the onset of hyperthyroidism. ● ● Excessive dietary intake of iodine: Excessive dietary intake of iodine can trigger hyperthyroidism onset. The most common type of hyperthyroidism is Graves’ disease, which is characterized by diffuse hyperfunction of the thyroid gland, increased thyroxine (T4) production, enlargement of the thyroid gland, and multiple system changes[5,6] . Graves’ disease is associated with ophthalmopathy, when the tissues and muscles behind the eyes become swollen causing the eyeballs to protrude. Graves’ disease may subside spontaneously[6] . Its exact cause is unknown but it occasionally coexists with abnormal iodine metabolism and other types of endocrine disorders[5] . The second most common type of hyperthyroidism is toxic adenoma, which is a small, benign nodule in the thyroid gland that secretes thyroid hormone. Its incidence is highest in the elderly, but its etiology is unknown. Toxic adenoma’s clinical manifestations are similar to those of Graves’ disease in many respects, but it does not cause ophthalmopathy[5,11] . Nor does it cause pretibial myxedema (localized skin lesions) or acropachy (soft tissue swelling with underlying bone changes at the site of new bone formation), which are also associated with Graves’ disease[5,11] . Remaining types of hyperthyroidism include [5,11] Thyrotoxicosis factitia is a form of hyperthyroidism that is due to chronic ingestion of thyroid hormone. The hormone is ingested by patients with thyroid carcinoma in an attempt to suppress TSH or by patients who are abusing thyroid hormone in an attempt to lose weight. Functioning metastatic thyroid carcinoma is a rare disease. It causes the thyroid gland to produce excessive amounts of thyroid hormone. A TSH-secreting pituitary tumor also causes excessive production of thyroid hormone. Subacute thyroiditis is a granulomatous inflammation of the thyroid that is triggered by a virus. It causes transient hyperthyroidism, fever, pain, pharyngitis, and thyroid gland tenderness. Silent thyroiditis is a transient form of hyperthyroidism that is self- limiting. Hyperthyroidism alert! Clinical hyperthyroidism can be triggered by excessive dietary intake of iodine or by stress in patients who have latent hyperthyroidism[5] . In Graves’ disease, an autoimmune reaction causes thyroid-stimulating antibodies to bind to and stimulate the TSH receptors of the thyroid gland. The cause of this autoimmune response is unknown. Disease development is associated with genetic factors, other autoimmune disorders, and the production of auto-antibodies formed because of a fault in suppressor T-lymphocyte function[11] .