Slide 1

Med/Surg I
Module 4, Part 2 of 4
Connective Tissue Diseases
Rheumatoid Arthritis
Lupus Erythematosus
Gout


Slide 2

Rheumatoid Arthritis
Pain, morning stiffness
 Early: Joint inflammation
 Late: deformities


Photo courtesy of Charles Goldberg, M.D., UCSD Image Bank,
http://medicine.ucsd.edu/clinicalimg/upper-rheumatoid-arthritis.html

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Slide 3

Complications
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Baker’s cysts: enlarged popliteal bursae
Synovitis, effusions in joints
Subcutaneous nodules: usually ulnar surface
of arm, fingers, along Achilles tendon
Sjogren’s syndrome: dry eyes, mouth and
vagina – secretory glands are obstructed
Felty’s syndrome: hepatosplenomegaly,
leucopenia
Caplan’s syndrome: rheumatoid nodules in
lungs
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Slide 4

Laboratory Assessment
Inflammatory connective tissue disease
 Rheumatoid factor (RF)
 Antinuclear antibody titer (ANA)
 Erythrocyte sedimentation rate (ESR)


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Slide 5

Collaborative Management
Analgesic/anti-pyretic/antiinflammatories
 Disease-modifying anti-rheumatic drugs
(DMARDs)
 Methotrexate (Rheumatrex): mainstay of
therapy
• Watch! For bone marrow suppression
& liver toxicity
 Lefunomide (Arava): Similar to
methotrexate, same side effects


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Slide 6

Collaborative Management, cont…
Immunosuppressants:
 Biological response modifiers:
 Glucocorticoids (steroids)
• Watch! Gastrointestinal
inflammation & blood sugar elevation
 Gold therapy


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Slide 7

Alternative Therapies
Hypnosis, acupuncture, imagery, magnet
or music therapy
 Omega-3 fatty acids: fish oil capsules
 Antioxidant vitamins A, C, E
 Trace elements: zinc, selenium, copper,
iron


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Slide 8

Non-pharmacologic Therapies
Rest and positioning for comfort
 Ice during inflammation
 Heat: paraffin wax dips or hot packs to
manage pain, increase mobility


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Slide 9

Lupus Erythematosus
•Discoid: affects only the skin
•Systemic: chronic, progressive connective
tissue inflammation causing nephritis (leading
cause of death), pericarditis, pleural effusions,
esophagitis, joint inflammation and inflamed
skin

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Slide 10

Collaborative Management: Discoid
Lupus
Rash: Topical cortisone
 Skin protection from sun, ultra-violet
 Teach: mild soap, no perfumes, use
lotion, avoid drying substances
 Alopecia (hair loss) is common: mild
protein shampoo


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Slide 11

Exacerbation
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Fever (major sign), abdominal pain, increased
fatigue, headache, dizziness
Caused by stress
Signs of inflammation in affected organs
Will need hospitalization, may become
rapidly critically ill

• Systemic corticosteroids
• Cytotoxics: Imuran, Cytoxan

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Slide 12

Gout


Manifestations:
Image Source: UCSD, Catalog of Clinical Images. Photography by Charlie Goldberg, M.D., University of California,
San Diego School of Medicine, San Diego VA Medical Center
http://medicine.ucsd.edu/clinicalimg/Upper-tophaceous-gout4.html

• Renal calculi (stones)
• Hyper-uricemia - elevated serum uric acid
• Joint inflammation - very painful
• Tophi - sodium urate crystal deposits,
commonly on outer ear, fingers

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Slide 13

Acute Episode of Gout

Sudden, severe joint pain and swelling
 Shiny red or purple skin around the
joint
 Extreme tenderness in the joint area


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Slide 14

Collaborative Management of Acute
Episode
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Colchicine (Colsalide)
NSAID
Allopurinol (Zyloprim) or probenecid (Benemid)
Watch! Aspirin and diuretics may start an attack
Avoid emotional stress
Low-urine diet: avoid organ meats, shellfish, oily fish
with bones
Avoid excess alcohol
Prevent stones - drink more fluids, increase acidity of
urine with alkaline ash foods (citrus, milk)

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Slide 15

Human Immunodeficiency
Virus (HIV)

Image Source: Wikimedia Commons, Public Domain, http://commons.wikimedia.org/wiki/Image:800pxHIV_Viron.png

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Slide 16

Diagnosis
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Leukopenia
Less than 500-16000 CD4+ cells/mm3 in AIDS
Enzyme-linked immunosorbent assay (ELISA)
Western blot
Viral load testing
Quantitative RNA assays
P24 Antigen assay

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Slide 17

Manifestations
HIV: Fever, chills, night sweats, headaches,
muscle aches
 AIDS: Signs of an opportunistic infection:


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shortness of breath or dry cough
fatigue
weight loss, nausea and vomiting, diarrhea
swollen lymph nodes
visual changes, memory loss and confusion
seizures, skin lesions
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Slide 18

Prevention
Sexual
 Parenteral
 Health care workers
 Perinatal
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Slide 19

Immunocompromised?
No crowds
 Don’t share personal items, bathe q day
 Wash hands, wash dishes, cups
 Low bacteria diet
 Avoid pet litter
 Check temperature daily
 No gardening


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Slide 20

Anti-HIV Drugs
Category

Action

Examples

Nucleoside analog
Inhibit HIV replication zidovudine (Retrovir),
reverse transcriptase
didanosine (Videx), zalcitabine
inhibitors
(HIVID),
Non-nucleoside
analog reverse
transcriptase
inhibitors

Suppress viral
replication, do not kill
the virus

nevirapine (Viramune), efavirenz
(Sustiva)

Protease inhibitors

Block protease
enzyme, prevents viral
replication

ritonavir (Norvir), indinavir
(Crixivan)

Fusion inhibitors

Block fusion of HIV
with host cell

enfuvirtide (Fuzeon)

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Slide 21

Opportunistic Infections
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Pneumocystis carinii (most common)
Toxoplasmosis gondii - from cat feces, undercooked meat
Candida albicans
Cryptococcus neoformans
Histoplasma capsulatum
Mycobacterium avium
Mycobacterium tuberculosis
Cytomegalovirus (CMV)
Herpes simplex
Kaposi’s sarcoma:
Image Source: Wikimedia Commons, Public Domain,
http://commons.wikimedia.org/wiki/Image:Kaposi%27s_Sarcoma.jpg

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Slide 22

Organ Transplants
Autograft
 Isograft
 Allograft
 Xenograft


Highest success rate
Highest success rate
↑ with compatibility
lowest success rate

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Slide 23

Nursing Care
Protect from infection
 Prevent rejection
 Patient teaching


Photo source: Wikimedia Commons,
http://commons.wikimedia.org/wiki/Image:Kidtransplant.jpg
Public Domain, US Government

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Slide 24

Transplant Rejection
Hyperacute: Immediate or up 2-3 days
after new tissue transplanted
 Acute: 1 week to 3 months after
transplant
 Chronic: 4 months to years after
transplant
 Graft-versus-Host Disease: First 100
days


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Slide 25

Rejection Prophylaxis/Rx
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Cyclosporine (Sandimmune, Neoral)
Azathioprine (Imuran)
Mycophenolate (CellCept)
Tacrolimus FK 506 (Prograf)
Sirolimus (Rapamune)
Corticosteroids (prednisone)
Interleukin-2 receptor antagonists
Antithymocyte globulin (Atgam)
Muromonab –CD3 (Orthoclone OKT3)
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Slide 26

Anaphylaxis
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Difficulty breathing
Wheezing
Abnormal high-pitched breath sounds
Confusion, slurred speech
Rapid, weak pulse, palpitations
Skin redness, hives, generalized itching
Profound hypotension
Bronchospasm and laryngospasm
Pulmonary edema
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Slide 27

Emergency Management

Airway: Assess for laryngospasm, stridor –
may need immediate intubation
Breathing: oxygen at high flow rate, 10-15
L/minute, monitor oxygen saturation
Circulation: Assess for dysrhythmias,
hypotension
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Slide 28

Reverse the Reaction
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Place tourniquet per protocol proximal to
allergen point of entry
Epinephrine (Adrenalin) intravenous: (Does
patient have an Epi-Pen?)
Diphenhydramine (Benadryl) intravenous
Dopamine for persistent hypotension to
vasoconstrict
Give antidote if appropriate
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Slide 29

Stabilize
Intravenous fluids: crystalloids, colloids
 Monitor for decompensation, repeat
epinephrine
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Slide 30

Diabetes Mellitus
Type 1
 Type 2
 Type 3 (gestational)
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Image Source: Wikimedia Commons, Public Domain,
http://commons.wikimedia.org/wiki/Image:Orange_juice_1.jpg

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Slide 31

Diagnosis
Fasting blood glucose
 Oral glucose tolerance test
 Glycosylated hemoglobin assay
(HgA1C)
 Serum protein and albumin
 24-hour urine creatinine clearance


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Slide 32

Common Signs and Symptoms of
Hyperglycemia


Other Symptoms Might Include

• Fatigue
• Blurred vision
• Weight loss
• Poor wound healing (cuts, scrapes, etc.)
• Dry mouth
• Dry or itchy skin
• Impotence (male)
• Recurrent infections such as vaginal yeast infections,
groin rash, or external ear infections (swimmers ear)

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Slide 33

Common Signs and Symptoms of
Hyperglycemia
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The Classic Symptoms
• Polyphagia (frequently hungry)
• Polyuria (frequently urinating)
• Polydipsia (frequently thirsty)

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Slide 34

Ketoacidosis
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Hyperglycemia: > 250 mg/dL
Dehydration: hot, dry, flushed skin
Metabolic acidosis: pH < 7.3
Electrolyte imbalance: loss of potassium,
sodium
Nausea and vomiting
Kussmaul’s respirations: increased rate and
depth
Ketone breath: fruity, alcohol-like
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Slide 35

Treatment for Ketoacidosis
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Fluid replacement
Replace electrolytes
Give insulin: Initial bolus dose followed by infusion of
regular insulin

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NOTE: insulin may adsorb into the plastic or glass container,
decreasing its potency – flush IV line with at least 50 ml of
insulin infusion before connecting to patient

Closely monitor blood sugar at least hourly
Keep a syringe of 50% dextrose immediately available for
hypoglycemia
Treat Acidosis

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Slide 36

Patient Education: Hyperglycemia
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Follow sick day rules
Monitor capillary glucose every 4 hours
Continue to take insulin or oral antidiabetic agents
Drink 8-12 ounces of liquids every hour
Continue to eat at regular times
Get plenty of rest
Call physician for persistent nausea, vomiting, glucose
elevation despite medication, high or increasing fever,
diarrhea

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Slide 37

Hyperosmolar Hyperglycemic
Non-ketotic Syndrome (HHNS)
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Type II diabetic, some insulin secreted
Ingests large amount sugar, decreased fluid
In HHNS the hyperglycemia is more
profound, increasing the blood osmolarity
and diuresis.

• Dehydration
• Electrolyte imbalance
• Decreased neurologic function
• Seizures

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Slide 38

Collaborative Management
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First priority: replace fluid volume with
intravenous saline.
The preferred solution is 0.45% saline to correct
the water deficit rapidly and the sodium deficit
more slowly (to prevent seizures)
Give 1000 ml/hr until central venous pressure,
blood pressure and urine output are adequate
Reduce the rate to 100-200 ml/hr until the
estimated water deficit is replaced
Monitor hourly for: cerebral edema, mental status
changes, abnormal neurologic signs, signs of fluid
overload
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Slide 39

Insulin:
 Intravenous

insulin is given at a rate of
10 units/hr to supplement blood
glucose reduction by rehydration.
 Blood sugar should decrease no faster
than 10% per hour.

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Slide 40

Insulin Injection Sites

Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

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Slide 41

Common Signs and Symptoms of
Hypoglycemia
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Early Symptoms

• Hunger
• Trembling
• Palpitations
• Anxiety
• Sweating
• Clamminess

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Slide 42

Late Symptoms Might Include
Difficulty thinking
 Confusion
 Headache
 Seizures
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Slide 43

Emergency Treatment:
Hypoglycemia
Glucagon intravenous or
 Dextrose 50% intravenous –
repeat according to blood
sugar
 NOTE: high glucose will
damage the tissue if it leaks
 5% dextrose in water
intravenously


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Slide 44

Patient Teaching: Hypoglycemia


Check blood sugar: if less
than 60 mg/dL:
• Treat with 15 grams of
glucose or equivalent
• Wait 15 minutes and
retest
• If blood sugar is still less
than 60 mg/dL, treat
with another 15 grams
of glucose
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Slide 45

To prevent hypoglycemia:
• Eat and take medications on time
• Make sure to eat enough food for the medication you are
•
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taking
Do not drink alcohol without eating food
Carry some form of carbohydrates with you in case there
is a meal delay
Be aware of the time of day - if you are taking insulin,
your blood sugar will be the lowest before a meal
Plan your exercise
Report all unexplained hypoglycemia episodes to your
doctor
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Slide 46

Diabetic Diet
Different
categories
 Portion size
 1600-2800
calories
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Diabetes Food Pyramid
Source: National Diabetes Education Program/NIH
http://ndep.nih.gov/diabetes/MealPlanner/pyramid.htm

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Slide 47

Diabetes Food Serving per Day
Grains and starches: 6-11
 Vegetables: 3-5
 Fruit: 2-4
 Milk: 2-3
 Meat and meat substitutes: 4-6 oz
 Fats, sweets and alcohol: 0?


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Slide 48

Glycemic Index


Ranks carbohydrate-rich foods according to their
glycemic response.

• Foods that raise the blood glucose level quickly have a

higher GI rating than foods that raise blood glucose level
more slowly. In general, the lower the rating, the better
the quality of carbohydrate.



Choose low and medium GI foods more often
than high GI foods.

• A GI of 55 or less ranks as low, a GI of 56 to 69 is
medium, and a GI of 70 or more ranks as high.

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Slide 49

LOW GLYCEMIC INDEX FOODS
(55 or less) choose most often
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Skim milk
Plain Yogurt
Soy beverage
Apple/plum/orange
Sweet potato
Oat bran bread
All-Bran™
Converted or Parboiled rice
Pumpernickel bread
Al dente (firm) pasta
Lentils/kidney/baked beans
Chick peas
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Slide 50

MEDIUM GLYCEMIC INDEX
FOODS (56-69) choose more often
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Banana
Pineapple
Raisins
New potatoes
Oatmeal
Split pea or
green pea
soup

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Brown rice
Couscous
Basmati rice
Shredded
wheat cereal
Whole wheat
bread
Rye bread
Popcorn
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Slide 51

Teach: Exercise

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Regular exercise is essential for carbohydrate
metabolism and insulin sensitivity.
Hypoglycemia can occur during and for 24
hours after exercise
• Check glucose levels before and after
exercise
• Do not exercise within one hour of
insulin injection or at peak insulin action
• Insulin dosage may need to be decreased
before exercise
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Slide 52

Teach: Exercise
(cont…)

A carbohydrate snack for exercise will help
maintain glucose levels: 15-30 g for every
30-60 minutes of exercise
 Take a simple sugar (hard candy) when
exercising if symptoms of hypoglycemia
occur
 Low intensity aerobic exercise for longer
periods is most effective


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Slide 53

Complications
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Cardiovascular disease
Kidney disease
Retinopathy
Neuropathy
Foot complications
Skin complications
Gastroparesis
Erectile dysfunction
Depression
Photo source: National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
http://diabetes.niddk.nih.gov/dm/pubs/medicines_ez/index.htm

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Slide 54

Transplantation


Whole pancreas or islet cell transplants will
provide normal glucose control. Organ or
cell availability continues to be limited.
Potential complications include:
• long-term immunosuppression
• venous thrombosis
• rejection
• infection
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Slide 55

Endocrine Organs
Hypothalamus
 Pituitary
 Thyroid
 Thymus
 Parathyroids
 Adrenal glands
 Pancreas
 Ovaries/Testes


Source: U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program
http://training.seer.cancer.gov/module_anatomy/unit10_3_dige_regions.html

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Slide 56

Pituitary Disorders
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Secondary hormonal imbalances

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Acromegaly

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Diabetes Insipidus

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SIADH

• TSH, ACTH, FSH

• Overproduction of growth hormone
• ADH deficiency
• Excess ADH
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Slide 57

Trans-Sphenoidal
Hypophysectomy
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Neuro checks
Watch! Diabetes Insipidus
Watch dressing: Postnasal drip?
Teach: avoid cough, blow nose, sneeze
Watch for Meningitis
Replace hormones

• Thyroid
• Glucocorticoids

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Slide 58

Thyroid Disorders
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Hyperthyroidism (Grave’s Disease)



Hypothyroidism (Myxedema)

• Fatigue, hair loss, cold intolerance,
constipation

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Slide 59

Thyroidectomy

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Position: Semi-fowler’s, avoid neck extension
Watch!

• Hemorrhage 1st 24 hours
• Laryngeal stridor
• Tetany (what are the early signs?)
• Laryngeal nerve damage
• Thyroid storm

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Slide 60

Parathyroid Disorders
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Hyperparathyroidism

• Hypercalcemia
• Bone damage



Hypoparathyroidism

• Muscle cramps
• Chvostek’s & Trousseau’s signs
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Slide 61

Adrenal Disorders


Addison’s crisis

• Hypovolemia, low Na+
• Hypoglycemia
• Hyperkalemia => acidosis



Cushing’s disease

• Moon face, buffalo hump, truncal obesity
• Hypertension
• Bruising
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Slide 62

Photo Acknowledgement:
All unmarked photos and clip art
contained in this module
were obtained from the
2003 Microsoft Office Clip Art Gallery.
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