Sandbox: hyperthyroidism 2

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]

Differentiating hyperthyroidism from other diseases

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According to the origin of the abnormality
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary hyperthytoidism
 
 
 
 
Secondary hyperthyroidism
 
 
 
 
Tertiary hyoperthyroidism
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Grave’s disease
Toxic thyroid nodule
Thyroid adenoma
Multinodular goiter
 
 
 
 
Pituitary adenoma
Intracranial tumors pressing pituitary gland
 
 
 
 
• Excess thyroxin production due to disorders of the hypothalamus which may be due to intracranial tumors or masses.
 

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According to iodine uptake

Hyperthyroidism can be classified according to the results of iodine uptake test into[1]

High iodine uptake

High or normal uptake:

Low uptake:

 
 
 
 
 
 
 
 
According to Iodine uptake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
High iodine uptake
 
 
 
 
High or normal uptake
 
 
 
 
Low uptake
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Graves' disease
Toxic multinodular goiter
Toxic thyroid adenoma
 
 
 
 
• Iodine caused hyperthyroidism
Hashitoxicosis
Germ cell tumors (choriocarcinoma in males and testicular germ cell tumors)
Pituitary TSH producing adenoma
 
 
 
 
Subacute thyroiditis
Hyperthyroidism due to ectopic thyroid tissue
• Factitious thyrotoxicosis
Struma ovarii
Painless thyroiditis
Amiodarone induced thyroiditis-Type 1
Amiodarone induced thyroiditis-Type 2
 
Disease Prominent clinical features Lab findings Images
Hyperthyroidism The main symptoms include:
  • The patient usually has elevated T3 and T4
  • TSH might be increased or decreased depending on the underlying cause
  • Thyroid stimulating antibodies (TSI) might be increased in cases of Graves’ disease
By Jonathan Trobe, M.D. - University of Michigan Kellogg Eye Center - The Eyes Have It, CC BY 3.0, https://commons.wikimedia.org/w/index.php?curid=16115992
Essential hypertension Most patients with hypertension are asymptomatic at the time of diagnosis. Common symptoms are listed below: JNC 7 recommends the following routine laboratory tests before initiation of therapy for hypertension:
  • 12-Lead electrocardiogram (ECG)
  • Urinalysis, including urinary albumin excretion or albumin/creatinine ratio
  • Blood glucose
  • Blood hematocrit
  • Serum electrolytes, especially potassium
  • Serum calcium
  • Lipid profile: Total cholesterol, LDL, HDL, triglycerides
  • Creatinine or estimated GFR
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Generalized anxiety disorder According to DSM V, the following criteria should be present to fit the diagnosis of generalized anxiety disorder:
  • The presence of sense of apprehension or fear toward certain activities for most of the days for at least 6 months
  • Difficulty to control the apprehension
  • Associated restless, fatigue, irritability, difficult concentration, muscle tension or sleep disturbance (only one of these manifestations)
  • The anxiety or the physical manifestations must affect the social and the daily life of the patient
  • Exclusion of another medical condition or the effect of another administered substance
  • Exclusion of another mental disorder causing the symptoms

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Menopausal symptoms The perimenopause symptoms are caused by an overall drop, as well as dramatic but erratic fluctuations, in the levels of estrogens, progestin, and testosterone. Some of these symptoms such as formication may be associated with the hormone withdrawal process.
  • B-HCG should always be done first to rule out pregnancy especially in women under the age of 45 years
  • FSH can be measured but it can be falsely normal or low
  • TSH, T3 and T4 to rule out thyroid abnormalities
  • Prolactin can be measured to rule out prolactinoma as a cause of menopause
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Opioid withdrawal disorder

According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:

  1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer) or administration of an opioid antagonist after a period of opioid use.
  2. Development of three or more of the following criteria minutes to days after cessation of drug use: Dysphoric mood, Nausea or vomiting, Muscle aches, Lacrimation or rhinorrhea, Pupillary dilation, piloerection, or sweating, Diarrhea, Yawning, Fever, Insomnia.
  3. The signs or symptoms mentioned above must cause impairment of the daily functioning of the daily activities of the patient
  4. The signs or symptoms mentioned above must not be attributed to other medical or mental disorders


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Pheochromocytoma The hallmark symptoms of a pheochromocytoma are those of sympathetic nervous system hyperactivity, symptoms usually subside in less than one hour and they may include:
  • Palpitations especially in epinephrine producing tumors.
  • Anxiety often resembling that of a panic attack
  • Sweating
  • Headaches occur in 90 % of patients.
  • Paroxysmal attacks of hypertension but some patients have normal blood pressure.
  • It may be asymptomatic and discovered by incidence screening especially MEN patients.

Please note that not all patients with pheochromocytoma experience all classical symptoms.

Diagnostic lab findings associated with pheochromocytoma include:
Left sided pheocromocyroma - Case courtesy of Dr Bruno Di Muzio, Radiopaedia.org, rID: 44813


According to DSM V, the following criteria should be present to fit the diagnosis of opioid withdrawal:

  1. Cessation of (or reduction in) opioid use that has been heavy and prolonged (i.e.,several weeks or longer) or administration of an opioid antagonist after a period of opioid use.
  2. Development of three or more of the following criteria minutes to days after cessation of drug use: Dysphoric mood, Nausea or vomiting, Muscle aches, Lacrimation or rhinorrhea, Pupillary dilation, piloerection, or sweating, Diarrhea, Yawning, Fever, Insomnia.
  1. [+http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(05)72981-0/abstract "Thyroid disease classification - The Lancet"] Check |url= value (help).