For patient with DM history, sugar monitor is indicated. In addition to underline disease control, history taking is the first priority, including medication history. Basic LAB data may provide further information for our treatment. Also, nutrition support could not be neglected.
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2014年12月24日 星期三
Subclinical hypothyroidism
For patients with subclinical hypothyroidism and TSH concentrations ≥10 mU/L, we suggest treatment with thyroid hormone (T4).
For non-older patients with TSH concentrations between 4.5 and 10 mU/L who have symptoms of hypothyroidism, we also suggest treatment with T4.
For older patients (over age 70 years) with subclinical hypothyroidism and TSH between 4.5 and 8 mU/L, we suggest "not" treating.
We recommend initiating T4 replacement in women with subclinical hypothyroidism (TSH values >2.5 mU/L) who are pregnant.
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For non-older patients with TSH concentrations between 4.5 and 10 mU/L who have symptoms of hypothyroidism, we also suggest treatment with T4.
For older patients (over age 70 years) with subclinical hypothyroidism and TSH between 4.5 and 8 mU/L, we suggest "not" treating.
We recommend initiating T4 replacement in women with subclinical hypothyroidism (TSH values >2.5 mU/L) who are pregnant.
2014年12月17日 星期三
Subclinical hyperthyroidism with multiple nodular goiter
Multinodular goiters was noted in our hospital in Sep. She did not compalined of any discomfort. Although operation and RAI will reduce the size of goiter and relieve symptoms, these treatment should be discussed with the patient first.
Autonomously functioning thyroid adenomas and multinodular goiters are the most common causes of endogenous subclinical hyperthyroidism. The LAB may be normal on retesting weeks or months later, so that intervention should not be considered unless persistently low TSH is noted.
Overt hyperthyroidism is associated with increased bone resorption, low bone density, and an increase in fracture. Patients with subclinical hyperthyroidism also have an increased risk of atrial fibrillation and have more subtle cardiac findings(increases in heart rate, cardiac contractility, and left ventricular mass). In patients at high risk for skeletal or cardiac complications, if the serum TSH <0.1 mU/L, we treat the underlying cause of subclinical hyperthyroidism. If the serum TSH is 0.1 to 0.5 mU/L, we suggest treatment if there is underlying cardiovascular disease or if the bone density is low or the radionuclide scan shows one or more focal areas of increased uptake. For patient with low risk for cardiac or skeletal complications with TSH <0.1 mU/L, we suggest treatment if the radionuclide scan shows one or more focal areas of increased uptake.
Thyroid echo was just preformed on 9/17. Microsomal Ab and TSHR Ab was negative then. There was no FNA data and it was not performed before(according to family statement). Thus, you may arranged aspiration cytology this time and recheck thyroid function later. However, the patient's will of invasive evaluation is not high. Please discusse with her and her family first.
Besides, Amiodarone may also cause mild Hyperthyroidism (3% to 10%). ARB may exaggerate CKD and induce hyperkalemia. Please evalute these drugs. You may also check ACTH and Cortisol, renin activity and aldosterone for hyperkalemia evalulation. Nephrologist may be consulted if necessary.
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Autonomously functioning thyroid adenomas and multinodular goiters are the most common causes of endogenous subclinical hyperthyroidism. The LAB may be normal on retesting weeks or months later, so that intervention should not be considered unless persistently low TSH is noted.
Overt hyperthyroidism is associated with increased bone resorption, low bone density, and an increase in fracture. Patients with subclinical hyperthyroidism also have an increased risk of atrial fibrillation and have more subtle cardiac findings(increases in heart rate, cardiac contractility, and left ventricular mass). In patients at high risk for skeletal or cardiac complications, if the serum TSH <0.1 mU/L, we treat the underlying cause of subclinical hyperthyroidism. If the serum TSH is 0.1 to 0.5 mU/L, we suggest treatment if there is underlying cardiovascular disease or if the bone density is low or the radionuclide scan shows one or more focal areas of increased uptake. For patient with low risk for cardiac or skeletal complications with TSH <0.1 mU/L, we suggest treatment if the radionuclide scan shows one or more focal areas of increased uptake.
Thyroid echo was just preformed on 9/17. Microsomal Ab and TSHR Ab was negative then. There was no FNA data and it was not performed before(according to family statement). Thus, you may arranged aspiration cytology this time and recheck thyroid function later. However, the patient's will of invasive evaluation is not high. Please discusse with her and her family first.
Besides, Amiodarone may also cause mild Hyperthyroidism (3% to 10%). ARB may exaggerate CKD and induce hyperkalemia. Please evalute these drugs. You may also check ACTH and Cortisol, renin activity and aldosterone for hyperkalemia evalulation. Nephrologist may be consulted if necessary.
2014年12月11日 星期四
Hyperlupedemia
In patients with mild to moderate hypertriglyceridemia (150 to 500 mg/dL), the main indication for therapy is reduction of cardiovascular (CV) risk. Lifestyle changes are a central part of managing such patients. Pharmacologic therapy with statin therapy for CV risk reduction has been best proven. Benefit from lowering the cholesterol with statins in patients without clinical evidence of CVD has also been demonstrated. Besides, glucocorticoids may cause peripheral insulin resistance, hyperinsulinemia, and increased VLDL synthesis.
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2014年12月9日 星期二
Suspected adrenal insufficency
Adrenal insufficiency is likely if the serum cortisol level is below 15 during critical condition or < 3 at 8:00 AM. Critically ill patients with established hypoadrenalism should be treated with hydrocortisone if no cintraindication. Ideally, a corticotropin test should be performed for diagnosis. If adrenal insufficiency is confirmed and ACTH levels are normal or high, further evaluation for mineralocorticoid deficiency should be performed (check PRA and aldosterone).
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