Page 57 Complete Your CE Test Online - Click Here therapeutic dose of digoxin. Cardiovascular effects are seen most often in elderly patients. ● ● CNS: These effects are most often seen in younger patients. They include trouble concentrating, nervousness, anxiety, mood swings, emotional instability that may progress to psychosis, tremors, and clumsiness. ● ● Gastrointestinal system: Anorexia, nausea, vomiting, diarrhea, and enlarged liver. ● ● Integumentary system: Warm, smooth, moist, thick, flushed skin. Loss of skin color in blotches. Fine and soft hair that begins to gray prematurely. Hair loss in men and women. Fragile nails. ● ● Musculoskeletal system: Muscle weakness and atrophy. ● ● Reproductive system: Menstrual abnormalities, impaired fertility, decreased libido, and higher incidence of spontaneous abortions in women. Gynecomastia and decreased libido may be found in men. ● ● Senses: Exophthalmos causes patients to blink less frequently. This leads to dry eyes, reddened conjunctiva and cornea, and corneal ulcers. Patients also have trouble looking upward and strabismus [5,11] . Treatment depends on any underlying causes, the presence and size of goiter, the age of the patient, disease severity, and any current complications[6] . General treatment initiatives include[5,6,11,16] : ● ● Anti-thyroid medications. Medication administration continues until normal thyroid levels are reached. This can take from three months to two years. If normal levels cannot be reached, radiation or surgical intervention is recommended. Medications must be discontinued gradually to prevent exacerbation. ● ● Beta blockers, although they do not prevent or inhibit thyroid hormone production, do limit the effects of excessive amounts of thyroid hormone on the body. ● ● Radioactive iodine therapy limits secretion of thyroid tissue by destroying tissue. It can cause a permanent remission of hyperthyroidism, but may also cause the patient to become permanently hypothyroid. ● ● Surgery to remove part of the thyroid gland is performed to reduce secretions. If most of the thyroid gland is removed life-long thyroid hormone replacement therapy is necessary. ● ● Ophthalmopathy is managed by OTC artificial tears during the day and lubricating gels at night. What is thyroid storm? What are its clinical manifestations? Thyroid storm is the most serious complication of hyperthyroidism. Also referred to as thyrotoxic crisis, thyroid storm usually occurs in patients with preexisting, though often undiagnosed, thyrotoxicosis. Untreated, it is usually fatal[5,11] . When excessive amounts of T3 and T4 are produced systemic adrenergic activity increases, which leads to overproduction of epinephrine. Excessive amounts of epinephrine cause significant hypermetabolism that, in turn, leads to rapid cardiac, gastrointestinal, and sympathetic nervous system decompensation. Hypertension, tachycardia, vomiting, extreme irritability, and temperature up to 106 °F can occur. Thyroid storm can progress to delirium, coma, and death. The onset of thyroid storm is abrupt and triggered by stressors such as trauma, surgery, infection, or serious events such as stroke, myocardial infarction, preeclampsia, or pulmonary embolism[11] . Differentiate among the various types of thyroiditis. Thyroiditis is defined as inflammation of the thyroid gland. It is most prevalent in people between the ages of 30 and 50 and is more common in women than in men[5] . The disease usually occurs in three phases: overactive thyroid, underactive thyroid, and return to normal [17] . For patients who do not experience a return to normal thyroid functioning, life-long follow-up and thyroid hormone replacement [5,19] . There are five types of thyroiditis: ● ● Postpartum thyroiditis: This is an uncommon disorder characterized by inflammation of the thyroid gland within the first year following childbirth. It is associated with an immune system reaction/underlying autoimmune thyroid condition [18,19] . Some women may experience signs and symptoms only of hyperthyroidism or only of hypothyroidism, but not both[18] . Most women who develop postpartum thyroiditis experience a return to normal thyroid function within 12 to 18 months[18] . ● ● Hashimoto’s thyroiditis: Hashimoto’s thyroiditis is a chronic progressive disease of the thyroid gland. It is an autoimmune disorder characterized by thyroid infiltration of lymphocytes. As the immune system “attacks” its own thyroid, the gland gradually swells, and damage is sustained [6,19]. Thyroid hormone levels are abnormally low. This type of thyroiditis cannot be cured, and low thyroid hormone levels are usually permanent. Thus, life-long thyroid hormone replacement is usually necessary[19] . ● ● Subacute thyroiditis: Subacute thyroiditis is a self-limiting, painful inflammation of the thyroid gland that usually occurs following a viral infection[5,6] . Ninety to 95% of patients experience a return to normal thyroid function. The remaining 10% experience permanent hypothyroidism and require life-long thyroid hormone replacement[6] . ● ● Riedel thyroiditis: Riedel thyroiditis is a rare, chronic inflammatory disease of the thyroid gland. The thyroid undergoes dense fibrosis that replaces normal thyroid parenchyma. Most patients retain normal thyroid functioning, but about 30% become hypothyroid[21] . ● ● Miscellaneous types: These include acute or infectious thyroiditis due to a bacterial infection; drug induced thyroiditis caused by various drugs (e.g. amiodarone); painless thyroiditis, which produces signs and symptoms similar to postpartum thyroiditis but is not associated with childbirth; and radiation induced thyroiditis that is triggered when radiation iodine treatment is used to treat overactive thyroid glands or for certain cancers[19] . Carla is an RN who works in a busy pediatric private office practice in the Great Lakes region. Mrs. Reynolds brings her three year old daughter in for a wellness checkup. Carla notices that Mrs. Reynolds has a slight swelling in the front of her neck and slight neck distention. Mrs. Reynolds seems to be breathing rather heavily even though she is sitting down. Carla offers her a cup of water, which Mrs. Reynolds refuses saying, “I must be getting a sore throat. I seem to be having trouble swallowing lately.” Although Carla’s clinical experience as a HCP has been primarily in pediatrics she begins to wonder if Carla has a thyroid problem. Carla encourages Mrs. Reynolds to see a physician. Mrs. Reynolds does so and later calls Carla to thank her. It turns out that Mrs. Reynolds does have a thyroid problem, but has normal levels of thyroid hormones. What type of thyroid problem does Mrs. Reynolds have? Mrs. Reynolds has been diagnosed as having a nontoxic goiter. It occurs when the thyroid gland is unable to secrete sufficient thyroid hormone to meet the needs of the body. The thyroid gland enlarges as a compensatory mechanism, which usually overcomes mild to moderate hormonal deficiencies. Hence, thyroid hormone levels are normal [5,11,22] . Treatment focuses on reduction of thyroid hyperplasia. The treatment of choice is thyroid hormone replacement therapy with levothyroxine dessicated thyroid or liothyronine, which inhibits secretion of TSH and allows the thyroid gland to rest[5,11] . Small doses of iodine in the form of Lugol’s solution or potassium solutions are given to patients whose goiter is caused by iodine deficiency[5,11] . Other treatment initiatives include[5,11] : ● ● Diet: Avoid foods such as cabbage, soybeans, peanuts, peaches, peas, spinach, strawberries, and radishes, which decease the production of T4[11,22] . ● ● Radiation: Radiation ablation therapy may be used to destroy cells that concentrate iodine for thyroid hormone production. ● ● Surgery: Large goiters that do not respond to other treatments may require partial removal of the thyroid gland. Accidental removal of parathyroid tissue during thyroidectomy may cause symptoms related to what electrolyte imbalance? Hypoparathyroidism is an uncommon condition caused by a deficiency of parathyroid hormone (PTH). Since PTH is essential to the regulation and maintenance of calcium and phosphorus, hypoparathyroidism is characterized by hypocalcemia and neuromuscular hyper-excitability [6, 23] . Characteristic signs of hypoparathyroidism include[5,6] : ● ● Tetany: Manifested by muscle hypertonia and tremors and spasmodic or uncoordinated movements triggered by attempts at voluntary movements.