Hyperthyroid Part I Self-Learning Module

Mr. Bill Loney Bill is a 72 year old man who lives alone in his small home. He reluctantly comes to the clinic you are at but says he refuses to, “spend all day on the pot anymore.” He also says that his eyes have really been bugging him and that he feels kind of mixed up now and again.

Vital Signs What do you expect his vital signs to be considering that hyperthyroidism increases metabolism and increases tissue sensitivity to sympathetic nervous system stimulation? Discuss and write down what you anticipate his vitals signs might be before continuing…

Vital Signs at Admission HR= 103 Heart sounds= irregular, murmur noted Respiratory rate=30 Lungs= short of breath but clear BP= 173/90 Temp= 38.2 C (100.7 F) Bowel sounds= hyperactive in all 4 quadrants

Standard I: Assessment Mr. Bill seems rather restless and maybe even a bit agitated. You notice he is under-dressed for this cool spring day and is actually sweating. You begin your head-to-toe assessment while Mr Bill talks about some of his symptoms.

Head to neck His forehead is sweaty and he says his tub has been clogged with his hair His eyes are bulged out from edema and fat deposits (exopthalmos) “I don’t have much of an appetite and I noticed that I’ve lost a few pounds”** **In the older adult client this finding is expected. For the middle-adult client, increased hunger and thirst is expected due to hypermetabolism.

Head to Neck Mr. Loney has a collared shirt on and opens it up so you can inspect his neck and chest. When he pulls back the color you notice a… Goiter

Chest and Abdomen Bounding, rapid heart rate. Murmurs and irregularity of rate are noted. “I sometimes get mild chest pains too.” He is short of breath from opening his shirt and moving to the exam table. Hyperactive bowel sounds. He says, “I have diarrhea three times a day.”

Hands His palms are reddened and his skin is quite warm. “And I can’t work on my model airplanes because my damn hands shake too much!” Clubbing of the fingernails. The nails are brittle, thin and some are detaching from the nail bed (onycholysis)

Lower Extremities Dependent edema in lower extremities. “My toes and ankles sure have been swollen and my muscles are just wasting away down there.” Pre-tibial myxedema (caused by deposits of hyaluronic acid in tissues)

Labs and Diagnostics You tell Mr. Loney that it appears that he may have hyperthyroidism and that further testing is needed including lab and diagnostic work. Discuss in your group what labs and diagnostics you might anticipate before continuing?

Labs Thyroid Stimulating Hormone (TSH) levels would be? Elevated Decreased Free thyroxine (FT4) levels would be? Elevated Decreased Surprised? Why aren’t TSH levels elevated like T3 and T4 levels?

Lab Data The body senses that there is too much thyroid hormone. Via a negative feedback loop the body actually over- suppress secretion of TSH. The feedback loop is “broken” because despite lower TSH levels, T3 and T4 levels continue to be high.

Diagnostics Radioactive Iodine Reuptake test helps differentiate the cause Chest X-ray: might show enlarged heart or compression of trachea/esophagus ECG: rules out cardiac involvement CT/MRI: to detect any tumors Goiter compressing a patient’s esophagus and trachea

Good work! You will hear more about Mr. Loney in the second half of class Make sure you complete the worksheet Refer to Table 48-4 pp and Table 48-7 on pp for a complete review of clinical manifestations