Focus on Hyperthyroidism (Relates to Chapter 50, “Nursing Management: Endocrine Problems,” in the textbook) Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 2 Hyperthyroidism  A sustained increase in synthesis and release of thyroid hormones by thyroid gland  Occurs more often in women  Highest frequency in 20- to 40-year- olds Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 3 Hyperthyroidism  Most common form Graves’ disease  Other causes Thyroiditis Toxic nodular goiter Exogenous iodine excess Pituitary tumors Thyroid cancer Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 4 Hyperthyroidism  Thyrotoxicosis Physiologic effects/clinical syndrome of hypermetabolism resulting from increased circulating levels of T 3, T 4  Hyperthyroidism and thyrotoxicosis occur together as Graves’ disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 5 Etiology and Pathophysiology Graves’ disease  Autoimmune disease of unknown origin Diffuse thyroid enlargement Excessive thyroid hormone secretion Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 6 Etiology and Pathophysiology Graves’ disease (cont’d)  Precipitating factors Insufficient iodine supply Infection Stressful life events interacting with genetic factors  Accounts for 75% of cases of hyperthyroidism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 7 Etiology and Pathophysiology Graves’ disease (cont’d)  Antibodies are developed to TSH receptor. Leads to clinical manifestations of thyrotoxicosis May progress to destruction of thyroid tissue, causing hypothyroidism Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 8 Etiology and Pathophysiology Toxic nodular goiters  Thyroid hormone–secreting nodules independent of TSH If associated with hyperthyroidism, termed toxic  Multiple or single nodules  Usually benign follicular adenomas  Occur equally in men and women Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 9 Clinical Manifestations  Related to effect of thyroid hormone excess ↑ metabolism ↑ tissue sensitivity to stimulation by sympathetic nervous system Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 10 Clinical Manifestations  Ophthalmopathy Abnormal eye appearance or function Exophthalmos Protrusion of eyeballs from the orbits  Impaired drainage from orbit  Increased fat and edema in retroorbital tissues  Seen in 20% to 40% of patients Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 11 Exophthalmos and Goiter of Graves’ Disease Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Exophthalmos and goiter of Graves’ disease.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 12 Clinical Manifestations  Cardiovascular system Bruit over thyroid gland Systolic hypertension ↑ cardiac output Dysrhythmias Cardiac hypertrophy Atrial fibrillation Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 13 Clinical Manifestations  GI system ↑ appetite, thirst Weight loss Diarrhea Splenomegaly Hepatomegaly Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 14 Clinical Manifestations  Integumentary system Warm, smooth, moist skin Thin, brittle nails Hair loss Clubbing of fingers Diaphoresis Vitiligo Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 15 Acropachy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. Fig Thyroid acropachy. Digital clubbing and swelling of fingers.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 16 Clinical Manifestations  Musculoskeletal system Fatigue Muscle weakness Proximal muscle wasting Dependent edema Osteoporosis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 17 Clinical Manifestations  Nervous system Fine tremors Insomnia Ability of mood, delirium Hyperreflexia of tendon reflexes Inability to concentrate Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 18 Clinical Manifestations  Reproductive system Menstrual irregularities Amenorrhea Decreased libido Impotence Gynecomastia in men Decreased fertility Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 19 Clinical Manifestations  Intolerance to heat  ↑ sensitivity to stimulant drugs  Elevated basal temperature Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 20 Complications Thyrotoxic crisis  Acute, rare condition, where all manifestations are heightened  Life-threatening emergency  Death rare when treatment initiated  Presumed causes are additional stressors. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 21 Complications Thyrotoxic crisis  Manifestations include Tachycardia Heart failure Shock Hyperthermia Restlessness Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 22 Complications Thyrotoxic crisis  Manifestations (cont’d) Agitation Seizures Abdominal pain Nausea Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 23 Complications Thyrotoxic crisis  Manifestations (cont’d) Vomiting Diarrhea Delirium Coma Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 24 Complications Thyrotoxic crisis  Treatment ↓ Thyroid hormone levels and clinical manifestations with drug therapy  Therapy Aimed at managing respiratory distress, fever reduction, fluid replacement, and management of stressors Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 25 Diagnostic Studies  History  Physical examination  Ophthalmologic examination  ECG  Radioactive iodine uptake (RAIU) Indicated to differentiate Graves’ disease from other forms of thyroiditis Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 26 Diagnostic Studies  Laboratory tests TSH Free thyroxine (free T4) Total T3 and T4 Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 27 Collaborative Care  Goals Block adverse effects of thyroid hormones. Stop hormone oversecretion. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 28 Collaborative Care  Three primary treatment options Antithyroid medications Radioactive iodine therapy (RAI) Subtotal thyroidectomy Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 29 Collaborative Care  Drug therapy Useful in treatment of thyrotoxic states Not considered curative Antithyroid drugs Iodine β-adrenergic blockers Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 30 Collaborative Care  Antithyroid drugs Inhibit synthesis of thyroid hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeks Therapy for 6 to 15 months Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 31 Collaborative Care  Antithyroid drugs (cont’d) Disadvantages include Patient noncompliance Increased rate of recurrence First-line examples Propylthiouracil (PTU)  Also blocks conversion of T4 to T3 Methimazole (Tapazole) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 32 Collaborative Care  Iodine Used with other antithyroid drugs in preparation for thyroidectomy or treatment of crisis Large doses rapidly inhibit synthesis of T3 and T4 and block their release into circulation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 33 Collaborative Care  Iodine (cont’d) ↓ vascularity of thyroid gland Maximal effect seen within 1 to 2 weeks Long-term iodine therapy is not effective. Examples Saturated solution of potassium iodine (SSKI) Lugol’s solution Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 34 Collaborative Care  β-adrenergic blockers Symptomatic relief of thyrotoxicosis resulting from β-adrenergic receptor stimulation Propranolol (Inderal) administered with other antithyroid agents Atenolol (Tenormin) is the preferred β- adrenergic blocker for patients with asthma or heart disease. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 35 Collaborative Care  Radioactive iodine therapy (RAI) Treatment of choice in nonpregnant adults Damages or destroys thyroid tissue Delayed response 2 to 3 months Treated with antithyroid drugs and Inderal before and during first 3 months of RAI Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 36 Collaborative Care  RAI (cont’d) High incidence of posttreatment hypothyroidism Need for lifelong thyroid hormone replacement Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 37 Collaborative Care  Surgical therapy Indications Unresponsive to drug therapy Large goiters causing tracheal compression Possible malignancy Individual not a good candidate for RAI Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 38 Collaborative Care  Surgical therapy (cont’d) Subtotal thyroidectomy Preferred surgical procedure Involves removal of significant portion of thyroid 90% removed to be effective Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 39 Collaborative Care  Surgical therapy (cont’d) Endoscopic thyroidectomy appropriate with small nodules and no malignancy Less scarring, pain, and recovery time Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 40 Collaborative Care  Surgical therapy (cont’d) Before surgery Antithyroid drugs, iodine, and β-adrenergic blockers may be administered  To achieve euthyroid state  To control symptoms Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 41 Collaborative Care  Nutritional therapy High-calorie diet may be ordered For hunger and prevention of tissue breakdown Protein allowance 1 to 2 g/kg ideal body weight Avoid caffeine, highly seasoned foods, and high-fiber foods Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 42 Nursing Management Nursing Assessment  Health history Preexisting goiter Recent infection or trauma Immigration from iodine-deficient area Medications Family history of thyroid or autoimmune disorders Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 43 Nursing Management Nursing Assessment  Weight loss  Nausea  Diarrhea  Dyspnea on exertion  Muscle weakness  Insomnia  Heat intolerance Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 44 Nursing Management Nursing Assessment  Decreased libido  Impotence  Amenorrhea  Irritability  Personality changes  Delirium Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 45 Nursing Management Nursing Assessment  Objective Data Agitation Hyperthermia Enlarged or nodular thyroid gland Eyelid retraction Diaphoretic skin Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 46 Nursing Management Nursing Assessment  Brittle nails  Edema  Tachypnea  Tachycardia  Hepatosplenomegaly Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 47 Nursing Management Nursing Assessment  Hyperreflexia  Fine tremors  Muscle wasting  Coma  Menstrual irregularities  Infertility Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 48 Nursing Management Nursing Diagnoses  Activity intolerance  Risk for injury  Imbalanced nutrition: Less than body requirements  Anxiety  Insomnia Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 49 Nursing Management Planning  Overall goals Experience relief of symptoms. Have no serious complications related to disease or treatment. Maintain nutritional balance. Cooperate with therapeutic plan. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 50 Nursing Management Nursing Implementation  Acute intervention Usually treated in outpatient setting Those with acute thyrotoxicosis or undergoing thyroidectomy require hospitalization and acute care. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 51 Nursing Management Nursing Implementation  Acute thyrotoxicosis Requires aggressive treatment Administer medications to block thyroid hormone production. Administer IV fluids. Ensure adequate oxygenation. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 52 Nursing Management Nursing Implementation  Acute thyrotoxicosis (cont’d) Calm, quiet room Cool room Light bed coverings Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 53 Nursing Management Nursing Implementation  Acute thyrotoxicosis (cont’d) Change linens frequently if diaphoretic. Encourage and assist with exercise. Establish supportive relationship. Apply artificial tears to relieve eye discomfort. Elevate HOB and salt restriction for edema. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 54 Nursing Management Nursing Implementation  Acute thyrotoxicosis (cont’d) Do eye exercises. Tape eyelids shut for sleep if they cannot close. Wear dark glasses to reduce glare and prevent environmental irritants. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 55 Nursing Management Nursing Implementation  Thyroid surgery Preoperative care Alleviate signs/symptoms of thyrotoxicosis. Control cardiac problems. Assess for signs of iodine toxicity. Oxygen, suction equipment, and tracheostomy tray are available in room. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 56 Nursing Management Nursing Implementation  Thyroid surgery (cont’d) Preoperative teaching Coughing, deep breathing, and leg exercises Supporting head while turning in bed Range-of-motion exercises of neck Speaking difficulty for a short time after surgery Routine postop care Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 57 Nursing Management Nursing Implementation  Thyroid surgery (cont’d) Postoperative care Every 2 hours for 24 hours  Assess for signs of hemorrhage.  Assess for tracheal compression.  Irregular breathing, neck swelling, frequent swallowing, choking Semi-Fowler’s position  Support head with pillows.  Avoid flexion of neck.  Tension on suture lines Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 58 Nursing Management Nursing Implementation  Thyroid surgery (cont’d) Postoperative care Monitor vitals. Control pain. Check for tetany.  Trousseau’s and Chvostek’s signs should be monitored.  Monitor for 72 hours. Evaluate difficulty in speaking/hoarseness.  Some hoarseness is expected for 3 to 4 days. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 59 Nursing Management Nursing Implementation  Ambulatory and home care Discharge teaching Monitor hormone balance periodically. Decrease caloric intake to prevent weight gain.  Adequate iodine Perform regular exercise. Avoid ↑ environmental temperature. Avoid goitrogens. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 60 Nursing Management Nursing Implementation  Ambulatory and home care (cont’d) Discharge teaching Regular follow-up care  Biweekly for a month and then semiannually After complete thyroidectomy  Lifelong thyroid replacement instruction Signs/symptoms thyroid failure Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 61 Nursing Management Evaluation  Relief of symptoms  No serious complications related to disease or treatment  Cooperate with therapeutic plan. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 62 When assessing a patient who is returned to the surgical unit following a thyroidectomy, the nurse would be most concerned if the patient: 1. Complains of thirst. 2. States her throat is sore. 3. Holds her head when she moves in bed. 4. Makes harsh, vibratory sounds when she breathes. Audience Response Question Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Case Study Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 63

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 64 Case Study  28-year-old woman visits her primary care physician’s office.  She states she is always hungry, yet has lost 15 lbs in the past few months. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 65 Case Study  She also claims to always be tired.  Her skin is warm and moist.  Her nails have become brittle. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 66 Case Study  She has a bounding pulse and a slight heart murmur.  Palpation of her thyroid reveals a nodular goiter. Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 67 Case Study  Labs reveal ↓ TSH ↑ free thyroxine (free T4) Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 68 Discussion Questions 1. What problem do her symptoms and lab values suggest? 2. What treatments may the patient require? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 69 Discussion Questions 3. What follow-up will she need with these treatments? 4. What important patient teaching should you do following these treatments? Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.