Primary Care in Gynecology

Chapter 9 Primary Care in Gynecology - Novak’s Gynecology page 199~230 Primary Care in Gynecology  Early diagnosis and treatment of medical illnesses can have a major impact on a woman’s health and is a key component of primary care.  Although timely referral is important for complex and advanced disorders, the gynecologist initially may treat many conditions Primary Care in Gynecology  Respiratory Infections  Sinusitis  Otitis Media  Bronchitis  Pneumonia  Cardiovascular Disease  Hypertension  Cholesterol  Endocrinologic Disease  Diabetes Mellitus  Thyroid Disease Respiratory Infection  Sinusitis  Otitis Media  Bronchitis  Pneumonia  Etiology Respiratory Infection Sinusitis Infection : begin with a viral agent in the nose or nasopharynx that cause inflammation that blocks the draining ostia.  Viral agents : impede the sweeping motion of cilia in the sinus and, in combination with the edema from inflammation, lead to superinfection with bacteria  Bacterial agents: S.pyogenes, S.pneumoniae, H. influenzae, Staphylococcus aureus α-hemolytic streptococcus species * G(-) organism : usually limited to compromised hosts in intensive care units * chronic disease : polymicrobial with mixed infections consisting of aerobic and anaerobic organisms.  Factors to contributing the development of sinus disease : atmospheric pollutants, allergy, tobacco smoke, skeletal deformities, dental conditions, barotrauma from scuba diving, airline travel, neoplasm, # chronic sinusitis : systemic disease (connective tissue syndrome), malnutrition Respiratory Infection Sinusitis  Clinical finding 1) maxillary toothache 2) poor response to nasal decongestants 3) abnormal transillumination 4) a colored nasal discharge established by history 5) a colored nasal discharge on examination - ≥4 : the likelihood of sinusitis↑ - none : the likelihood of sinusitis ↓ Respiratory Infection Sinusitis  Diagnosis  self-diagnosed : headache, dental pain, postnasal drainage, halitosis, dyspepsia  Imaging studies : not when initial episodes , but when persistent infections occur Respiratory Infection Sinusitis  Treatment  Broad antibiotic therapy : cover common aerobes and anaerobes patient with acute pain & purulent discharge  Systemic decongestants: pseudoephedrine  Topical decongestants : < 3days d/t rebound vasodilation and worsening of symptoms  Mucolytic agents (guaifenesin) : help thin sinus secretions and promote drainage  Antihistamins : avoided in acute sinusitis d/t drying effects may lead to thickened secretions and poor drainage of the sinuses.  Symptomatic therapies : facial hot packs and analgesics  Chronic sunusitis : from repeated infection with inadequate drainage  Sx: recurrent pain in the malar area or chronic postnasal drip associated with chronic cough and laryngitis with intermittent acute infection  Treatment - directed at the underlying etiology : allergy control or aggressive management of infections - Resistant cases : CT - Endoscopic surgery : polyp remove  Complication (- untreated sinus-) : orbital cellulitis leading to orbital abscess, subperiosteal abscess formation of the facial bones, cavernous sinus thrombosis, acute meningitis, brain & dural abscess (rare) Respiratory Infection Sinusitis Respiratory Infection Otitis Media  Serous otitis media  Cause : 2nd to a concurrent viral infection of the upper respiratory tract  Diagnosis : reveals fluid behind the tympanic membrane  Treatment : symptomatic Tx with antihistamines, decongestants, glucorticoids but, little data exist supporting use of these medications Respiratory Infection Otitis Media  Acute otitis media  Cause : bacterial infection - Streptococcus pneumoniae, H. influenzae  Sx . : acute purulent otorrhea, fever, hearing loss, leukocytosis  P. Ex : red, bulging or perforated membrane  Treatment : Broad-spectrum antibiotics - amoxicillin-clavulanic acid, cefuroxime, trimithoprim-sulfamethoxazole * antihistamines in treatment of otitis media is unclear  Acute bronchitis : inflammatory condition of the tracheobronchial tree  Causes - viral infection and occurring in winter : common cold viruses(rhinovirus and coronavirus), adenovirus, influenza virus, Mucoplasma pneumoniae (nonviral pathoen) - bacterial infections : less common and 2nd pathogens  Sx Period Initial 3~4days ~3wks Sx cough, hoarseness , fever rhinitis and sore throat : prominent coughing : prominent Respiratory Infection Bronchitis # coughning & sputum (prolonged in cigarette smokers) : m/c Sx Respiratory Infection Bronchitis  Diagnosis  P.Ex : Auscultation : coarse rhonchi (rales: not usually not auscultated ) signs of consolidation and alveolar involvement : absent.  chest x-ray : to detect the presence of parenchymal disease  sputum culture  Treatment  symptomatic relief : uncomplictated cases  antibiotics : for patients who have chest radiographic findings consistent with pneumonia  atitussives (containing either dextromethorphan or codeine) : coughing (most aggravating symptom)  expectorants : efficacy –not been proved Respiratory Infection Bronchitis  Chronic bronchitis : defined as the presence of a productive cough with excessive secretions for 3months in a year for 2 consecutive years  Prevalence : estimated to be 10-20% of the adult population  Classified as a form of chronic obstructive disease (COPD)  Causes chronic infection and environmental pathogens found in dust  Sx cardinal manifestation : incessant cough,-usually in the morning , with expectoration of sputum Sinusitis Otitis media bronchtis Pneumonia  Definition : Inflammation of the distal lung that includes terminal airways, alveolar spaces and the interstitium  Causes : Viral , bacterial, aspiration pneumonia  Aspiration pneumonia cause : depressed awareness commonly associated with use of drugs, alcohol or anesthesia  viral pneumonia : multiple infection - influenza A or B, parainfluenza, respiratory syncytial virus : spread by aerosolization associated with coughing, sneezing, conversation * intubation time : short, requiring only 1~3days prior to the acute onset of fever, chills, headache, fatigue and myalgia Respiratory Infection Pneumonia Respiratory Infection Pneumonia * pneumonia develops in only 1% of patients who have a viral syndrome - mortality rates : 30% in immunocompromised individuals and the elderly * Staphylococcal pneumoniae (2nd bacterial pneumonia) : arising from a previous viral infection, extremely lethal * vaccination : influenza, pneumococcal pneumonia amantadine : used to treat individual who have not been vaccinated (in epidemics) * Treatment : supportive care – antipyretics and fluids  Bacterial pneumonia Respiratory Infection Pneumonia  Classification : Nosocomial or community acquired - determine the prognosis and choice of antibiotic therapy  Risk factors : chronic cardiopulmonary diseases, alcoholism, DM, renal failure, malignancy, malnutrition  Signs and Symptoms : depending on the infecting organism and the patient’s immune status Typical Causes Streptococcus pneumoniae. Hemophilus influenzae, Klebsiella pneumoniae, G(-) organisms, anaerobic bacteria ( cause 2/3 of all bacterial pneumonias) Sudden onset high fever, rigors, productive cough, chills, pleuritic chest pain disclosed infiltrates pneumonia Atypical Viruses, Mycoplasma pneumoniae, Legionella pneumophila, Chlamydia pneumoniae … Symptoms Incidious onset Moderate fever without the characteristic rigors and chills Nonproductive cough, headache, myalgias, mild leudocytosis Bronchopneumonia with a diffuse interstitial pattern (“bat wing distribution “) Radiology Respiratory Infection Pneumonia  Laboratory studies  Gram stain, sputum & blood culture * sputum collection : neutrophil > 25/LPF epithelial cell < 10/LPF  ELISA ( indirect serologic test) or direct fluorescent antibody staining of organisms in the sputum : Lesionella pneumoniae  cold agglutinin c appropriate clinical symptoms : Mycoplasma pneumoniae Respiratory Infection Pneumonia Hospitalization Treatment Very ill, elderly, immunocompromised - Oxygen therapy and hydration with antibiotic therapy (same protocol for outpatient therapy except 3rd –generation cephalosporin) - Chest physiotherapy # Switch to Oral antibiotics : ability to eat and drink, blood culture (-), temperature <38℃ respiratory rate ≤24bpm pulse rate≤100bpm # Discharge - after switch to oral antibiotics - WBC 12X109 /L - comorbid illnesses are stable - O2 saturation >90% on room air or patient with COPD : PO2>60mmHg and PCO2<45mmHg Outpatient Without coexisiting conditions such as heart disease, lung disease, renal insufficiency, liver disease or other comorbid medical illnessess in patient ≤60years - Erythromycin(500mg, qid) - Clarithromycin (500mg, bid) or Azithromycin (500mg, qd for 1 day, followed by 250mg qd for 4days) – esp. smoker or intolerance to erythmycin - Doxicycline (100mg bid) : for patients who are allergic or intolerant to macrolides With coexisiting conditions such as heart disease, lung disease, renal insufficiency, liver disease, or other comorbid medical illnessess in patient ≤60years - 2nd –generation cephalosporin or - β-lactam-β-lactamase inhibitor : amoxicillin-clavulanic acid - With or without a macrolide if legionellosis is a concern  Vaccination  Peumococcal vaccination - Indication : ≥ 65, heart, lung disease, alcoholism, renal failure, DM, HIV infection, cancer - repeat vaccination : recommended 5years after the 1st dose in high risk group  influenza vaccination - Indication : ≥50years, serious long term health problems like heart disease, lung disease, kidney disease, DM, immunosuppression 2nd to long-term steroid or cancer therapy, 3rd trimester of pregnancy during the flu season and anyone coming into close contact with people at risk of serious influenza (physicians, nurses, family members) * best time : October~mid November Respiratory Infection Pneumonia Respiratory Infection Pneumonia  poor prognosis factor : involvement >2 lobes, respiratory rate >30breaths/minute on arrival in the health care center, severe hypoxemia (<60mmHg breathing room air), hypoalbuminemia and septicemia  Complication : ARDS (mortality rate : 50~70%) Cardiovascular Disease  Hypertesion  Hyperlipidemia Cardiovascular Disease Risk factors Cardiovascular Disease Hypertension  Epidemiology -In U.S. : 15% of the population between the ages of 18 and 74 years  Incidence : increases with age and varies with race >50 years : female > male African Americans > Whites : twice Geographic variations : higher prevalence of hypertension and stroke in the southeastern United States regardless of race  Definition : blood pressure levels ≥140/90 when measured on two separate occasions  Primary or essential hypertension : >95%, cause unknown  Secondary hypertension : <5%  Diagnosis - Hx and P.Ex : presence of prior elevated readings, previous use of antihypertensive agents, a family history of death from cardiovascular disease prior to age 55, excessive alcohol and sodium use → lifestyle modification is increasingly important in the therapy of hypertension - Laboratory evaluations : rule out reversible causes of hypertension (secondary hypertension) UA, CBC, S/E, Cr, fasting glucose, total cholesterol, HDL cholesterol, EKG … Cardiovascular Disease Hypertension  Measurement of Blood Pressure - patient should be allowed to rest for 5minutes in a seated position and the right arm used for measurements (for unknown reason, the right arm has higher readings) - cuff should be applied 20mm above the bend of the elbow and the arm positioned parallel to the floor - The cuff should be inflated to 30mmHg above the disappearance of the brachial pulse or 220 mmHg - the cuff should be deflated slowly at a rate ≤ 2mmHg/sec # cuff size : important cuff hypertension : small cuffs used for obese patients  Diastolic reading : - Phase IV : Korotkoff’s sounds (muffled sound) - Phase V : complete disappearance Cardiovascular Disease Hypertension Cardiovascular Disease Hypertension Diagnosis and management are based on the classification of blood pressure readings Cardiovascular Disease Hypertension Cardiovascular Disease Hypertension  Treatment - General guidelines in assessing individuals for therapy Cardiovascular Disease Hypertension Medication 1) Diuretics Thiazides (eg.hydrochlorthiazide) Reduce plasma and ECF vol •→ decreanse peripheral • resistance, initially • decrease of cardiac • output •→ then normalize •m/c used medication for • initial BP reduction • Cr level <2.5g/L •Better than tiazide diuretics at lower GFR and higher Scr •+NSAIDs →limits the effectiveness of thiazides •Acute gout, DM (glucose intolerance) hyperlipidemia •Thiazides +Loop diuretics •: cause profound diresis →lead to renal impairment •Hyperuricemia •Hyperglycemia •Hyperlipidemia •hypokalemia •Same as above •hypocalcemia mechanism Indication Contra Ix Side effect Loop diuretics (eg. furosemide) * Potassium-sparing diuretics (spironolactone, triamterene or amiloride) 2) Adrenergic Inhibitors Β-blockers •Propranolol •Β1 selective •(atenolol) •Decreasing cardiac output and plasma renin activity c some increase in total peripheral resistance •Migraine •Angina, MI •tachycardia •Asthma, DM, COPD, sick sinus syndrome, bradyarrhythmia, •NSAIDs → decrease the effectiveness of β-blockers •Depression •Sleep disturbaces(nightmares in the elderly) •constipation •Metabolic change (similar to those of thiazides) •AMI(by rebound phenomenom) Orthostatic hypotension tachcardia, weakness, dizziness, mild fluid retension α1-adrenergic Prazosin doxazosin Promote vascular relaxation Total cholesterol LDL cholesterol ↓ HDL cholesterol↑ •Males •(minimal effects on potency) •Stress urinary incontiness •+diuretics →hypotension exacervated •Elder Medication Angiotensin-converting Enzyme Inhibitors(ACEi) •Captopril •Enalapril •Enalprilat Angiotensin Receptor Antagonists •Losartan •Calsatan Calcium-channel Blockers •Verapamil •Nifedipine •Nicardipine •Direct Vasodilators •Hydralazine •Minoxidil (limited use to the gyecologist d/t side effect –beard growth) •Central-acting Agents •Metyldopa •clonidine Mechanism Indication Asthma, COPD, depression ,DM, Peripheral vascular disease •* combination with diuretics, CCB, β-blockers ContraIx •Pregnancy •+ NSAIDs: decrease the effectiveness •+diuretics : hypovolemia Side effect • Chronic cough • Hypotension • blooddyscrasias, rashes, loss of taste , fatigue, headaches hyperK •Interfere with the binding of angiotensin II to AT-I receptor •Block Ca movement across smooth m. →promoting vessel wall relaxation •Protecting the heart and kidney •CAD, •elder •Heart failure, conduction disturbance •Headache, dizziness, constipation, peripheral edema •Direct relaxation of vascular smooth m. primarily arterial •Preeclampsia, eclampsia •Headaches, Tachycardia (→β –blocker) • fluid (Na) retension (→diuretics) Drug-induced lupus erythematousus •Taste disorder •Dry mouth •Suddent withdrawal of clonidine: hypertensive crisis and induce angina •Inhibit the sympathetic nervous system→peripheral vascular relaxation Cardiovascular Disease Hypertension  Choice of drugs  migraine headache : β-blockers or CCB  DM : ACEi  MI : β-blockers  African Americans: diuretics + CCB  Monitoring Therapy  Lifestyle modification (slightly elevated BP) - Interval : 1~2 week  With other disease (i.e.cardiovascular or renal) - lifestyle modification alone is successful : close monitoring - interval 3~6month - lifestyle modification is unsuccessful: medication Cardiovascular Disease Hyperlipidemia Cholesterol : esterized form with various proteins and glycerides that chrarcterize the stage of metabolism  Important lipid particles in cholesterol metabolism  Chylomicrons : large lipoprotein particles - dietary triglycerides + cholesterol secreted in the intestinal lumen, absorbed in the lymph, and then passed into general circulation adhered to binding sites on the capillary wall and are metabolized for energy production. (in adipose tissue and skeletal muscle )  Lipoprotein Particle : consisted three major component - core : consists of nonpolar lipids (triglycerides & cholesterol ester) - surface coat of phospholipids : made of apoproteins & structural proteins  Apoprotein : attached to all lipoprotein particles have specific receptors and demarcate the stage of cholesterol metabolism Cardiovascular Disease Hyperlipidemia  Lipoprotein classes :determined by the separation of lipids in an electrophoretic field  Prehepatic metabolites : CM and Remnants  Posthepatic metabolites : VLDL , IDL, LDL., HDL  Metabolism Cardiovascular Disease Hyperlipidemia  Hyperlipoproteinemia  TG:choesterol > 5:1 - predominant fractions are chylomicrons and VLDL  TG : cholesterol < 5:1 - problem of VLDL and LDL fraction  Initial classification Cardiovascular Disease Hyperlipidemia  Laboratory testing multiple environmental causes of variation in cholesterol measurements < major sources of variation > - diet, obesity, smoking, ethanol intake, effects of exercise - clinical conditions : hypothyroidism, DM, acute or recent MI, recent weight changes - other : fasting state, position while the sample is drawn, use and duration of venous occlusion . Anticoagulant and storage and shipping conditions  Intraperson variation  Age and sex Cardiovascular Disease Hyperlipidemia < 50years, in women lower lipid values than men > 50 years, women lipid value increase d/t exogenous oral conjugated estrogens  Seasional variation  Diet and obesity  Alcohol and cigarette smoking : moderate (defined as approximately 2ounces of absolute alcohol/day) sustained alcohol intake is noted to HDL ↑ LDL ↓, TG ↑ - this effect is negated with higher quantities  Smoking : LDL cholesterol and TG ↑, HDL cholesterol ↓ (critical number : 15~20 / day)  Exercise : TG and LDL↓ HDL↑  Caffeine mixed effect on lipoprotein measurements, avoid in the 12hours prior to blood collection  * Blood sample : collected in the morning after a 12-hour fast Cardiovascular Disease Hyperlipidemia  Disease States and Medication Effects - Diuretics, propranolol: TG↑, HDL cholesterol↓ (esp. Diuretics : total cholesterol ↑) - DM : TG & LDL↑ HDL cholesterol↓ - Pregnancy : total serum cholesterol ↓in 1st trimester, continuous increases of all fractions in 2nd~3rd trimester - Hypothyroidism : total cholesterol and LDL cholesterol ↑ Cardiovascular Disease Hyperlipidemia  Management  Once hyperlipidemia is confirmed on at least two separate occasions, 2nd causes should be diagnosed or excluded by taking a detailed medical and drug history, measuring Scr, fasting glucose level, performing thyroid, LFT  obese patients : diet and weight loss (1st)  Exercise and cigarette cessation Figure 9.4 Treatment decisions based on the LDL cholesterol level Cardiovascular Disease Hyperlipidemia Medication effect Adverse effect Bile acid-binding resins Nicotinic acid cholestyramine and colestipol LDL↓HDL↑ Constipation, bloating , nausea, heartburn Flushing, pruritus, G-I distress c aspirin or ibuprofen : minimize the facial flushing TG, LDL, lipoprotein(a)↓ HDL↑ Clofibrate, gemfibrozil Atorvastatin, fluvastatin, lovastatin, pravastatin simvastatin TG↓, HDL↑ LDL↑(some pts) Fibric acid derivatives HMG-CoA reductase inhibitors (-statin) Effect in cardiovascular disease Severe myalgias, muscle weakness c increases in creatine phosphokinase levels, rarely hhabdomyolysis leading to renal failure  Definition : chronic disorder of altered carbohydrate, protein and fat metabolism from deficiency in the secretion or function of insulin : defined by either fasting hyperglycemia or elevated plasma glucose levels after an oral glucose tolerance test (OGTT)  Risk factors - age >45years - adiposity or obesity - a family history of diabets - Race and ethnicity - Hypertension (≥140/90) - HDL cholesterol ≤35mg/dL with or without a TG level ≥ 250mg/dL - History of gestational diabetes or delivery of baby >9 pound Endocrinologic Disease Diabetes Mellitus Endocrinologic Disease Diabetes Mellitus  Classification  Type 1 DM : The major metabolic disturbance of type 1 diabetes is the absence of insulin from destruction of β cells in the pancreas  Type 2 DM : heterogeneous form of disbetes that commonly occurs in older age groups (>40 years) and is more frequently noted to have familial tendency than type 1 diabetes. # type 1 : an absence of insulin type 2 : resulting in insulin resistance Endocrinologic Disease Diabetes Mellitus  Diagnosis 1. FBG (fasting blood glucose) ≥ 126mg/dL 2. Random blood glucose ≥200mg/dL with classic signs and symptoms of diabetes (polydipsia, polyuria, polyphagia and weight loss) 3. 2-hour OGTT (fasting sample, 60 and 120 minute samples) after a 75g load of glucose → 2-hour OGTT should not be performed if the first two criteria are present. * Diagnostic criteria for imparied glucose intolerance (IGT)testing : 110mg/dL≤FRG<126mg/dL Endocrinologic Disease Diabetes Mellitus  Indication of DM testing - Age ≥45years (repeat at 3-year intervals) - Classic signs and symptoms of diabetes (i.e. polyuria, polydipsia, polyphagia and weight loss) - Ethnic groups at high risk (Pacific Islanders, Native Americans, Africal Americans, Hispanic Americans, Asian Americans) - Obesity - First-degree relative with diabetes - Gestational diabetes or birth of a baby over 9 pound - Hypertension (≥ 140/90) - HDL cholesterol levels≥35mg/dL or triglyceride level ≥250mg/dL - Impaired glucose tolerance based on previous testing Endocrinologic Disease Diabetes Mellitus Endocrinologic Disease Diabetes Mellitus  Treatment Endocrinologic Disease Diabetes Mellitus  Complication  Acute complication - Diabetic ketoacidosis (DKA) - Nonketotic hyperosmolar diabetic coma (NKHC) - Hypoglycemia - Lactoacidosis  Chronic complication - Macroangiopathy: accelerated atherosclerosis (CHD, MI, CVA…) - Microangiopathy : retinopathy, nephropathy, neuropathy - Other : infection, skin lesion Endocrinologic Disease Thyroid Disease  Thyroid disorders are more common in women and some families, although the exact inheritance is unknown.  In geriatric populations, the incidence ≒5%  Thyroid function tests may be misleading in women receiving exogenous sources of estrogen because of altered binding characteristics (i.e. hormonal replacement therapy, pregnancy)  Hypothyroidism  Hyperthyoidism  Thyroid Nodules and cancer Endocrinologic Disease Hypothyroidism  Incidence - overt hypothyroidism :2% of women, and at least an additional 5% develop subclinical hypothyroidism ( subclinical hypothyroidism : defined as an elevated serum TSH concentration with a normal serum free T4 level) Endocrinologic Disease Hypothyroidism  Causes - Autoimmune thyroiditis (Hashimoto’s thyroiditis) - incidence increases with age - associated with other endocrine (e.g. type 1DM, primary ovarian failure, adrenal insufficiency and hypoparathyroidism) and nonendocrine disorders (e.g. vitiligo and pernicious anemia) - Familial predisposition ( specific genetics or environmental trigger is unknown) - Iatrogenic cause : after surgical removal or radioactive iodine therapy for hyperthyroidism of thyroid cancer - Secondary to pituitary or hypothalamic diseases from TSH or TRH deficiency Endocrinologic Disease Hypothyroidism  Clinical Features - Fatigue, lethargy, cold intolerance, nightmares, dry skim, hair loss, constipation, periorbital carotene deposition (causing a yellow discoloration), carpal tunnel syndrome and weight gain(<5~10kg) menstrual dysfunction (menorrhagia or amenorrhea - Infertility (d/t anovulation) : exogenous thyroid hormone is not useful for women who are anovulatory and euthyroid - Neuropsychiatric symptoms : depression, irritability, impaired memory and dementia in the elderly - Not cause of premenstrual syndrome (PMS), but worsening PMS may be a subtle manifestation of hypothyroidism - Precocious or delayed puberty Endocrinologic Disease Hypothyroidism  Diagnosis : confirmed with laboratory studies - Serum TSH↑, s-T4 or free T4 index ↓, - Autoimmune thyroiditis : confirmed by the presence of serum antithyroid peroxidase (antimicrosomal) antibodies * Central hypothyroidism : low or low-normal serum free T4 with either a low or inappropriately normal serum TSH concentration Endocrinologic Disease Hypothyroidism  Treatment - L-thyroxine(T4), levothyroxine (Synthroid of Levothroid) : absorption may be poor when taken in combination with aluminum hydroxide (common in antacids), cholestyramine, ferrous sulfate or sucralfate because of binding or chelation - Normal daily dosage : 0.1~0.15mg (maintain TSH levels within the normal range)  Incidence : affects 2% of women during their lifetimes most often during their childbearing years * Graves’ disease represents the most common disorder  Causes - Graves’ disease - Transient thyrotoxicosis : result of unregulated grandular release of thyroid hormone in postparum (painless, silent or lymphocytic) thyroiditis and subacute (painful) thyroiditis - Other : hCG-secreting choriocarcinoma, TSH-secreting pituitary adenoma, and struma ovarii - Factitious ingestion or iatrogenic overprescribing Endocrinologic Disease Hyperthyroidism Endocrinologic Disease Hyperthyroidism  Clinical feature - Fatigue, diarrhea, heat intolerance, palpitations, dyspnea, nervousness, and weight loss. (In young patients : paradoxical weight gain from an increased appetite) - Vomiting in pregnant women- confused with hyperemesis gravidarum - P/Ex ) Tachycardia, lid lag, tremor, proximal m. weakness and warm, moist skin - Dramatic physical change : ophthalmologic and lid retraction , periorbital edema and proptosis, : 1/3 of women - In elderly adults : symptoms are often more subtle with presentations of unexplained weight loss, atrial fibrillation or new-onset angina pectoris - Menstrual abnormalities : regular menses, light flow, anovulatory menses and associated infertility Endocrinologic Disease Hyperthyroidism - Goiter : in younger women (m/c) c Graves’ disease - Toxic nodular goiter is associated with nonhomogeneous glandular enlargement while in subacute thyroiditis the gland is tender, hard and enlarged  Diagnosis - Total and free T4 and T3 ↑ (measured by radioimmune assay[RIA]) - in thyrotoxicosis , S-TSH concentrations: undetectable - Radioiodine uptake scans : useful in the differential diagnosis of established hyperthyroidism * Thyroiditis and medication-induced thyrotoxicosis : glandular radioisotope concentration↓ Endocrinologic Disease Hyperthyroidism  Treatment  Antithyroid medication : PTU ( 50~300mg q6~8hours) or methimazole(10~30mg/day) : relapse rate : 50% over a lifetime - minor side effects : fever, rash or arthralgias - major toxicity (<1%) : hepatitis, vasculitis, agranulocytosis  Radioiodine  Surgical resection  Iodine-131 : permanent cure of hyperthyroidism in 70~80%of patients  β-blocker (propranolol) : control of sympathomimetic symptoms (tachycardia), peripheral conversion of T4→T3 Endocrinologic Disease Hyperthyroidism  Thyroid storm :started immediately PTU, β-blockers, glucocorticoids and high-dose iodine preparations (SSKI or intravenous sodium sodium iodide)  Incidence : common and found on P.Ex in ≥5% of patients  Character : most nodules- asymptomatic and benign - Malignant tendency : irradiation in childhood,  Diagnosis - TFT→ FNA→thyroid scan - Biopsy: provides a diagnosis in 95% of cases  Malignanacy - Papillary thyroid carcinoma (m/c) :75% of cases associated cervical lymph node metastasis, usually cured - Aplastic tumors : poor prognosis and progress rapidly despite therapy  Treatment : Radioiodine therapy or surgical ablation Endocrinologic Disease Thyroid Nodule and Cancer