Endocrine Nurses Symposium Thyroid Grand Rounds

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Endocrine Nurses SymposiumThyroid Grand Rounds

• David S. Cooper
• Naomi Walpert
• Sinai Hospital of Baltimore
• Bryan Haugen
• Beverly McLaughlin
• University of Colorado

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Patient 1

• A 24 year-old woman develops palpitations, heat
  sensitivity, trouble sleeping, and has lost
  approximately 10 pounds despite a normal
  appetite.
• She sees her primary care doctor who notes some
  prominence of her eyes and an enlarged thyroid.
• A serum TSH is drawn which returned at lt0.004
  mU/l
• She is referred to the endocrine clinic for
  further evaluation

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Patient 1

• In addition to the symptoms she reported to her
  primary care doctor, the patient has developed
  amenorrhea for the last three months.
• She has no significant past medical history.
• Her mother has a history of hypothyroidism.
• She takes no medications and has no allergies.
• She works as a bank teller. She smokes one half
  to one pack of cigarettes daily. She drinks
  alcohol socially. She is engaged to be married.

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Patient 1

• On physical exam, pulse 100/minute, blood
  pressure 150/60, weight 99 pounds
• There is mild swelling around the eyes
  (periorbital edema) and some protrusion of the
  eyes (proptosis or exophthalmos)
• Extraocular movements are full
• Thyroid gland is two-fold enlarged, rubbery,
  smooth, and symmetrical
• The heart, lungs, and abdomen are unremarkable
• There is a fine tremor of the outstretched hands.
  The skin is warm and moist.

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Patient 1

• What is the diagnosis?
• What laboratory studies should be obtained?
• What is the best treatment?
• What are some of the medical and nursing issues?

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Patient 1

• The following laboratory data returned
• Free T4 2.5 ng/dl, T3 400 ng/dl, TSH lt0.004
• Pregnancy test negative
• The patient decides that antithyroid drug therapy
  is most appropriate for her.
• She is started on methimazole 20 mg daily as well
  as atenolol 50 mg daily.

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Patient 1

• One week later, she calls to report a diffuse
  itchy rash.
• What would you recommend?

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Patient 1

• One week later, she calls to report a diffuse
  itchy rash.
• What would you recommend?
• Nursing issues, medical issues

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Patient 1

• Methimazole is stopped, and the patient is
  treated with antihistamines with resolution of
  her symptoms.
• Rather than trying PTU, she prefers definitive
  radioactive iodine therapy
• What are the medical and nursing issues about
  receiving radioactive iodine in this young woman
  who smokes cigarettes and who lives with her
  fiancé?

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Patient 1

• The patient is treated with radioactive iodine
  and atenolol is continued.
• She does not return for follow-up and 4 months
  later she develops cold intolerance and fatigue.
• She is seen in the endocrine clinic and complains
  of these symptoms as well as a 20 pound weight
  gain.
• Her physical examination shows pulse 70/minute,
  blood pressure 135/85, weight 120 pounds
• There is mild proptosis. The thyroid gland is not
  palpable

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Patient 1

• Her skin is pale and dry and her reflexes are
  delayed in the relaxation phase.
• What has happened?
• Thyroid function tests are as follows
• Free T4 0.5 ng/dl, TSH 62 mU/l
• What should be done now?
• What are the medical and nursing issues?

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Patient 1

• The patient is started on levothyroxine 100 µg
  daily and atenolol is discontinued
• What are the medical and nursing issues?

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Patient 1

• Two months later the patient calls to report that
  she just found out that she is pregnant.
• What are the medical and nursing issues?

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Patient 2

• A 72 year-old woman is found to have a thyroid
  nodule on a routine physical examination and she
  is referred to the endocrine clinic for further
  evaluation
• She has no compressive symptoms including
  dysphagia, hoarseness, neck pain, or shortness of
  breath. She has no symptoms suggesting hyper-or
  hypothyroidism.
• The patient has no prior history of thyroid
  disease, no family history of thyroid disease,
  and no history of head and neck irradiation.
• she has a history of depression and coronary
  artery disease
• The nodule is approximately 3 x 3 cm on the left
  side. It is smooth, rubbery, nontender and
  mobile.

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Patient 2

• What should be done next?
• Thyroid function tests are as follows
• Free T4 1.3 ng/dl, TSH 1.3 mU/l
• A thyroid sonogram shows a 2.5 x 2 by 2.7 cm
  hypoechoic nodule with internal blood flow on the
  left. There is also a 0.9 x 0.8 x 0 .9 cm
  hypoechoic nodule on the right side.
• What is the next step?

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2.2
2.6
2.2
1.5
Transverse
Longitudinal
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Patient 2

• FNA of the larger nodule is performed under
  ultrasound.
• What are the medical and nursing issues?
• The results are as follows
• cellular specimen with areas of atypia and
  scattered microfollicles with scant colloid.
  Although this may represent a hyperplastic
  nodule, a follicular neoplasm cannot be excluded.

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FNA Categories
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Patient 2

• What should be done next?
• A thyroid scan is performed which shows a cold
  region corresponding to the nodule.
• What should be done next?

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Patient 2

• The patient is referred for surgery.
• She undergoes a total thyroidectomy. The nodule
  on the left is a follicular adenoma. The nodule
  on the right is a papillary cancer measuring 1.2
  x 1.2 by 1.3 cm.
• What should be done next?
• What are the medical and nursing issues?

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Patient 2

• It is decided that the patient should receive
  radioactive iodine therapy. Because of the
  relatively low risk of her tumor, her age, and
  underlying comorbidities, it is decided treat her
  using recombinant human TSH.
• What are the medical and nursing issues?
• Following the therapy, she is started on
  levothyroxine.
• What are the medical and nursing issues?

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Thank you for your attention!