© 2018 Kurt Pfeifer.

Thyroid Disease

ASSESSMENT

Data Gathering

History

Symptoms

  • Cause of thyroid disease (eg, surgical, thyroid cancer, radiation)

  • Recent dose adjustments

  • Previous treatments

  • Fatigue

  • Generalized weakness

  • Weight changes

  • Palpitations

  • Edema

  • Abnormal menses

  • Hair loss

  • Changes in bowel habits

Exam

  • Abnormal deep tendon reflexes

  • Edema

  • Hypertension

  • Tachycardia

  • Hair loss

  • Thyromegaly or thyroid nodules

Risk Stratification

Diagnostic Studies

  • Basic metabolic panel within 6 months (more recently if any change in status)

  • TSH within 6 months (more recently if any change in status

  • Free T4 if abnormal TSH, possible secondary (central) hypothyroidism, or history of thyroid cancer

  • Thyroid imaging: reserved for newly diagnosed thyroid disease

MANAGEMENT

Indications for Surgical Delay

  • Symptomatic or severe (free T4 <75% of lower limit of normal) hypothyroidism

  • Hyperthyroidism

    • If related to excessive thyroid hormone replacement, risks are generally considered lower than in primary hyperthyroidism​

  • Equilibration of thyroid laboratory studies takes 6-8 weeks after initiation or adjustment of thyroid hormone supplementation​

Medication Management

  • Thyroid hormone supplementation: continue at previous dose; no need to convert to IV if NPO for <4-5 days due to extended half-life of levothyroxine

  • Anti-thyroid medications (ie, propylthiouracil, methimazole): continue at previous dose

  • Patients with severe hyperthyroidism who require urgent surgery are at risk for adrenal insufficiency, and stress-dose glucocorticoids or heightened vigilance for adrenal insufficiency are required