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Hypothyroidism

Etiology
Deficient thyroid hormone secretion can be due to thyroid failure (primary hypothyroidism) or pituitary or hypothalamic disease (secondary hypothyroidism). Transient hypothyroidism may occur in silent or subacute thyroiditis. Subclinical (or mild) hypothyroidism is a state of normal thyroid hormone levels and mild elevation of TSH; despite the name, some patient may have minor symptoms. With higher TSH level and lo free T! level, symptoms become more readily apparent in clinical hypothyroidism. "n areas of iodine sufficiency, autoimmune disease and iatrogenic causes are most common. Clinical Features Symptoms of hypothyroidism include lethargy, dry hair and s#in, cold in tolerance, hair loss, difficulty concentrating, poor memory, constipation, mild eight gain ith poor appetite, dyspnea, hoarse voice, muscle cramping, and menorrhagia. $ardinal features on e%amination include bradycardia, mild diastolic hypertension, prolongation of rela%ation phase of deep tendon refle%es and cool peripheral e%tremities. &oiter may be palpated, or the thyroid may be atrophic and non palpable. $arpal tunnel syndrome maybe present. $ardiomegaly maybe present due to pericardial effusion. The most e%treme presentation is a dull, e%pression less face, sparce hair, periorbital puffiness, large tounge and pale, doughy, pulse s#in. The condition may progress into hypothermic, stuporous state (mi% edema coma) ith respiratory depression. 'actors that predispose to mi% edema coma include cold e%posure, trauma, infection, and administration of narcotic. Diagnostic Decreased serum T! is common to all varieties of hypothyroidism. (n elevated TSH is sensitive mar#er of primary hypothyroidism. Thyroid pero%idase (T)*) antibodies are increased in +,-+./ of patient of autoimmune-mediated hypothyroidism. 0levated cholesterol, increase creatine phospho#inase, and anemia may be present ; bradycardia, lo amplitude 12S comple%es, and flattened or inervated T ave maybe present on 0$&.

$auses of Hypothyroidism Primary (utoimmune hypothyroidism 3 Hashimoto thyroiditis, atropic thyroiditis "atrogenic 3 454" treatment, subtotal or total thyroidectomy, e#sternal irradiation of nec# for limfoma or cancer. Drugs 3 "odine e%cess, lithium, antithyroid drugs, P-aminosalicyclic acid,interferonalfa and other cyto#ines, aminoglutethimid $ongenital hypotyroidism 3 absent or ectopic thyroid gland, dyshormono genesis, TSH-2 mutation "odine deficiency "nfiltrative disorders 3 amyloidosis, sarcoidosis, hemochromatosis, scleroderma, cystinosis, riedel6s thyroiditis Transient Silent thyroiditis, including postpartum thyroiditis Subacute thyroiditis Withdra al of thyro%ine treatment in individuals ith an intact thyroid (fter 3 454 " Treatment or subtotal thyroidectomy for &rave6s disease Secondary Hypopituitarism 3 tumors, pituitary surgery or irradiation, infiltrative disorders, Sheehan6s syndrome, trauma , genetic forms of combined pituitary hormone deficiencies "solated TSH deficiency or inactivity 7e%arotene treatment Hypothalamic disease 3 tumors, trauma, infiltrative disorders, idiopatic Treatment (dult )ts 89, years ithout evidence of heart disease may be started on .,-4,,:g of ith #no n coronary artery disease, the starting dose of ee#s T! daily. "n the eldery or in )ts

T! is 4;,.-;.:g<d. the dose should be ad=usted in 4;,.-;.:g incremens every 9-> replacement dose is 4,9(:g<#g)<d.

on the basis of TSH levels, until a normal TSH levels is achieved. The usual daily omen on lephothyro%ine repalacement should have a TSH levels chec#ed as soon as pregnancy is diagnosed, as the replacement dose typically

increase by 5,-.,/ during pregnancy. 'ailure to recogni?e and treat maternal hypothyroidism may adversaily affect fetal neural development. Therapy for a mi%edema, should include T! and liothrioinine as a single "@ bolus follo ed by daily treatment T! and liotrioinine, along support, space balan#ets, and therapy of precipitating factors. ith ith hydrocorticone for impaired adrenal reserve, ventilatory

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