USMLE Internal Medicine Review 11 14 Thyroid Storm

USMLE Internal Medicine Review 11 14 Thyroid Storm

On these “Gold Standard Internal Medicine Facts” pages you will find Free:

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Let’s start our USMLE Review with Hypothyroidism and Hyperthyroidism from the Gold Standard USMLE Foundations of Medicine Audio Review program.

 

Play USMLE Audio MP3 11 14 Thyroid Storm Below

 

Begin 11 14 Thyroid Storm Transcription

The most dramatic complication of thyrotoxicosis is thyrotoxic crisis, more colloquially called what?

  • Thyroid storm. Thyroid storm is basically the acute exacerbation of all the symptoms of thyrotoxicosis presenting as a syndrome which can be life threatening. Conversely, thyroid storm can be mild and present only as an unexplained febrile reaction.

In a patient in what setting?

  • After thyroid surgery, in a patient who is inadequately prepared.

More commonly, thyroid storm occurs after surgery or after what type of therapy for thyroid disease?

  • Radioactive iodine therapy.

Thyroid storm can also occur during parturition in a patient in what setting?

  • During parturition in a patient with inadequately controlled thyrotoxicosis.

What is a synonym for parturition?

  • Childbirth.

Thyroid storm can also occur during severe stressful illness. Please pause the tape and try to name 5 illnesses which appear particularly predisposed to inviting thyroid storm syndrome.

  • Illnesses which seem to invite thyroid storm include acute infection, myocardial infarction, severe drug reaction, trauma, and uncontrolled diabetes.

Student doctor please pause the tape and introduce thyrotoxic crisis or thyroid storm. Please include a definition and the settings in which thyroid storm is most likely to occur.

  • Thyrotoxic crisis or thyroid storm is a serious complication of thyrotoxicosis. It is basically the acute exacerbation of all the symptoms of thyrotoxicosis and can range in severity from a post thyroid surgery febrile reaction in a patient who’s been inadequately prepared to a life threatening syndrome in its more severe manifestations. Thyroid storm occurs most commonly in the following settings: after surgery or after radioactive iodine therapy, during parturition in a patient with inadequately controlled thyrotoxicosis, or during severe stressful illnesses, particularly acute infection, myocardial infarction, severe drug reaction, trauma, and uncontrolled diabetes.

There are 2 chief clinical manifestations of thyroid storm. First, the term for above normal heat production by the body?

  • Hypermetabolism.

And second, excessive response of which system relating to nerve cells or fibers that employ Norepinephrine as their neurotransmitter?

  • Excessive adrenergic response.

What is probably the single most striking clinical diagnostic feature of thyrotoxic crisis out of proportion to other findings?

  • Hyperpyrexia, with fevers ranging from 38-41°C and associated with flushing and sweating.

And what is the principle cardiac feature of thyroid storm?

  • The chief cardiac feature of thyroid storm is marked tachycardia, often with atrial fibrillation, high pulse pressure, and occasionally heart failure. Heart failure with shock is likely fatal.

Please name 4 central nervous system symptoms of thyroid storm from least to most serious.

  • CNS symptoms of thyroid storm include marked agitation and restlessness, delirium and coma.

How about 4 gastrointestinal symptoms of thyroid storm in any order?

  • GI symptoms of thyroid storm include diarrhea, jaundice, nausea and vomiting.

Student doctor please pause the tape and summarize the clinical manifestations of thyrotoxic crisis or thyroid storm. Please include 2 chief categories of symptoms followed by the single most striking diagnostic feature of thyroid storm, along with common cardiac, CNS, and GI symptoms.

  • The 2 chief clinical manifestations of thyrotoxic crisis or thyroid storm are marked hypermetabolism and excessive adrenergic response. The single most striking diagnostic feature is hyperpyrexia, with fevers ranging from 38-41°C and associated with flushing and sweating. The principle cardiac symptom is marked tachycardia, often with atrial fibrillation, high pulse pressure, and occasionally heart failure. Heart failure with shock is likely fatal. Common CNS symptoms of thyroid storm include marked agitation and restlessness, delirium and coma, while GI symptoms often include diarrhea, jaundice, nausea and vomiting.

It was previously believed that thyroid storm was from sudden release of stored Thyroxine and tri-Iodothyronine from a thyrotoxic gland. Then it was found that serum levels of T4 and T3 in patients with thyroid storm were not higher than thyrotoxic patients without the syndrome. Please pause the tape and describe briefly the more current theory on the cause of thyrotoxic crisis. It involves TBG and catecholamine-binding sites. There is evidence that in thyrotoxicosis the number of catecholamine-binding sites increases while there is decreased binding to TBG (Thyroid-binding globulin). This elevates free T3 and T4. In this setting acute illness, infection or surgical stress can trigger an outpouring of catecholamines which in association with high levels of free T3 and T4 precipitates the syndrome of thyrotoxic crisis.

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