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Abstract: Patients 1, female, 18 years old, due to emotional instability, irritability 2 years, 1 day attending consciousness. 2 years ago, were in emotional instability, hyperactivity much to say and busybodies, and irritability, tension, worry, often with aggressive behavior of others, at the local clinic for "schizophrenia", long-term oral "chlorpromazine hydralazine "treatment. 1 day ago found that patients with family members of patients consciousness, and chlorpromazine in his side found empty bottles. Physical examination: Bp 70/50mmHg, P124 times / min, moderate coma, peripheral limbs, slightly cold and wet, two pupil diameter 1.5mm, proptosis negative sign, the number of pages: Page 1 Page Range :245-245 Key words: hyperthyroidism misdiagnosed psychiatric drug therapy of high depressive symptoms of metabolic syndrome subject classification: R581.1 [medicine, HEALTH "within SCIENCES" endocrine diseases and metabolic dise Thyroid Dis Hyperthyroidism] Related Articles: Topics related references ( 1) citations (1) coupling the literature (13)
Disease Over
According to their different causes of hyperthyroidism can be divided into several types, the most common is diffuse goiter, Graves disease accounts for about 90% of all men and women may be the disease, but more common in young women. Male to female ratio: 1:4 ~ 6. Hyperthyroidism is a common disease, according to etiology are divided into primary hyperthyroidism (Graves), secondary hyperthyroidism, high-func


tioning adenomas. The most common primary hyperthyroidism, is a autoimmune disease, secondary hyperthyroidism is less common, the change from nodular goiter. Hyperthyroidism is more difficult to cure incurable diseases, although not a chronic problem, but because of too much thyroid hormone secretion caused by high metabolic diseases. The current prevalence rate of 2% of female population, and the increasing trend year by year. Because people lack of knowledge of prevention, often overlooked can be healed. To suddenly increase the symptoms of hyperthyroidism reason to endanger the life of a state (mainly high fever, sweating, extreme tachycardia, vomiting, diarrhea, irritability, severe coma, if not save, can lead to death.) Clinical also There is a very easy to misdiagnosis of hyperthyroidism is Graves Hashimoto, Hashimoto's disease often have symptoms of hyperthyroidism early performance did not fully diagnose the disease simply by Graves disease, the primary disease treatment will be ignored. The occurrence of the disease pathogenesis by the various causes of blood caused by excessive thyroid hormone. And a variety of mental stimulation (sadness, anger, shock, fear, etc.) causing the nervous system (especially the hypothalamus - pituitary - thyroid axis) dysfunction occurs when an important factor in hyperthyroidism. Department of the disease certain autoimmune diseases, but its pathogenesis has not been fully elucidated. One of the features present in the serum and thyroid tissue has to react or stimulating autoantibodies, the antibody can stimulate the thyroid gland in rodents and improve its function and cause tissue proliferation, but its role in the slow and persistent. Thus named the thyroid-stimulating immunoglobulin (TSI) or thyroid stimulating antibody (TSAb) and other clinically referred to as TSH receptor antibody (TRAb), based disease lymphocytes secreted IgG, q the corresponding antigens by TSH body or near the surface of the part of the thyroid cell membrane, when the TSI when combined with the thyroid cells, TSH receptor is activated by the stimulation of thyroid function which caused hyperthyroidism and goiter, and its role and function exactly like TSH. That autoantibodies are the major genetic defects associated with the inhibition of T lymphocytes (Ts) function to lower them. Ts T cell functional defects in inappropriate secondary sensitization, and may be due to virus infection in interleukin-1 and the role of IL-2 with the participation of the B cells to produce antibodies against its own thyroid. Immune monitoring alone can not explain some of the specific immune defects in disease, but also linked to the genotype-order joint mechanism. Excessive secretion of the pathophysiology of the pathophysiology of thyroid function are many, but its mechanism has not been fully elucidated. In recent years, studies have found that thyroid hormones can promote phosphorylation, mainly through the stimulation of membrane Na-K-ATP enzyme (ie Na-K pump), the latter in the maintenance of cell Na-K gradient inside and outside the process requires a lot of energy to promote the active transfer of Na, resulting in an increase in ATP hydrolysis, thus contributing to mitochondrial oxidative phosphorylation, the results of oxygen consumption and heat production were increased. Although the role of thyroid hormones are manifold, but mainly in the promotion of protein synthesis, and promote heat production, as well as with each other to promote the role of catecholamines, which affect the various metabolic and organ function. Such as thyroid hormone can increase the basal metabolic rate and accelerate the consumption of many nutrients, muscle is also easy to consume. Thyroid hormones and catecholamines synergies to strengthen the latter in the nervous, cardiovascular and gastrointestinal tract and other organs of the excitement and stimulation. In addition, thyroid hormone on the liver, heart and intestines have a direct stimulating effect. Non-infiltrative exophthalmos caused by the increased sympathetic activity, infiltrative exophthalmos is unknown reasons, probably autoimmune mechanisms. Inducing factor induced hyperthyroidism and autoimmune disease, is closely related to genetic and environmental factors, of which the most important autoimmune factors. Unfortunately, the incidence of thyroid autoimmunity, the development is not clear so far, making it difficult to find preventive measures. Genetic factors are also important, but the genetic background and the way is not clear genetic, so it is difficult from the genetic aspects of prevention. Environmental factors including the incidence of hyperthyroidism induced by factors such as trauma, mental stimulation, infection, although many of hyperthyroidism induced mainly autoimmune, genetic factors, but the hair but not the incidence and environmental factors are closely related. In case of triggers for the disease, while avoiding triggers is not sick. Thus, the incidence of some patients with hyperthyroidism is possible to avoid the triggers under the conditions of prevention. (1) infection: such as colds, tonsillitis and pneumonia. (2) injury: If a car accident, trauma and so on. (3) Mental stimulation: such as stress, anxiety and so on. (4) fatigue: If overworked and so on. (5) Pregnancy: early pregnancy may induce or aggravate hyperthyroidism. (6) excessive iodine intake: If a large number of eating seaweed and other seafood. (7) of certain drugs: such as amiodarone and so on. There are many types of major types of hyperthyroidism, one of the most common is Graves disease Graves. Diffuse toxic goiter and autoimmune disease with genetic and other factors, but whether the symptoms of hyperthyroidism occur, and some predisposing factors (environmental factors) related. If you avoid these triggers symptoms of hyperthyroidism may not occur, or a delayed symptoms of hyperthyroidism, or alleviate the symptoms of hyperthyroidism. In addition to the typical clinical common than hyperthyroidism have: (1) T3 hyperthyroidism. T3 hyperthyroidism refers to the clinical manifestations of hyperthyroidism, but the serum TT4 and FT4 is normal or even low, only T3 increased in a class of hyperthyroidism. (2) T4 hyperthyroidism. Also known as thyroxine hyperthyroidism refers to the serum TT4, FT4 increased, and TT3, FT3 normal a class of hyperthyroidism. 1975, Turner reported on the T4 hyperthyroidism first name, and its typical clinical manifestations of hyperthyroidism and the same can occur in Graves disease, toxic nodular goiter or thyroiditis, generally less common in middle-aged, such as serious infection, surgery, malnutrition and other patients. TT4 and FT4 serum laboratory tests increased, TT3 and FT3 normal. 131I was significantly higher intake of thyroid, thyroid tablets or T3 suppression test abnormalities. The disease needs and acute stress hyperthyroidism (false T4 hyperthyroidism) phase identification. The so-called stress in patients with hyperthyroidism is suffering from various acute or chronic systemic disease, because the relationship between these diseases, serum TT4, FT4 increased, and TT3, FT3 normal or reduced, except for a few patients outside accompanied by goiter , there was no other evidence of hyperthyroidism, when the primary disease cured, the laboratory parameters returned to normal shortly. (3) children hyperthyroidism. Onset after the age of 3, 11-16 years gradually increased the highest incidence, more girls than boys, almost all children have a diffuse goiter and typical high metabolic syndrome, exophthalmos more common. (4) Elderly hyperthyroidism. Physiological changes as the elderly, the body organ function impaired in varying degrees, a degree of thyroid tissue fibrosis and atrophy, decreased thyroid hormone secretion and peripheral tissue responses to thyroid hormone changes, senile hyperthyroidism clinical features: often not enlarged thyroid, or mild swelling, it usually nodules; exophthalmos with or without obvious exophthalmos, high metabolic syndrome was not obvious, lack of appetite, hyperactivity, sweating and irritability and other heat intolerance symptoms; often associated with other heart diseases such as angina, or myocardial infarction, arrhythmia and heart failure-prone, more common sustained atrial fibrillation; patients showed no desire apathy was like, severe drowsiness or showed stupor, coma. (5) apathetic hyperthyroidism. The performance type is a special type of hyperthyroidism. Typical symptoms of hyperthyroidism symptoms contrary, showed a kind of nervous depression hyperthyroidism. Apathetic hyperthyroidism clinical manifestations: loss of appetite, nausea, chills, dry skin, look apathy, depression, indifference to the things around; mental retardation thinking activities, while slow to answer questions, and sometimes, difficulty concentrating, lazy action of few words; palpitations by the common, often accompanied by cardiac enlargement, congestive heart failure, atrial fibrillation, sunken eyes, eyes dull, Gao lag, or a drooping eyelid. (6) occult hyperthyroidism. Occult hyperthyroidism is no typical symptoms of hyperthyroidism, and the outstanding performance of a system of disease is a type of hyperthyroidism. clinical types have the spirit of type, in order to highlight the performance of mental disorder, the patient showed lack of concentration, attention and lax, hallucinations, delusions, depression, dementia, paranoia, mania, and even suicidal ideas, rage attacks and so on. gastrointestinal type, often to highlight the performance of diarrhea. More common in young patients, stool frequency to ten times ranging from several times a day, a paste or water samples, containing undigested food, vomiting or abdominal pain in some patients as the main performance. Gastrointestinal hyperthyroidism vomiting, diarrhea, often accompanied by water and electrolyte disorders, serious illness if not treated properly are likely to cause thyroid crisis, life-threatening. type myopathy, weakness and periodic paralysis as the main performance. Obvious symptoms of hyperthyroidism or appeared later. Clinical manifestations of acute and chronic thyrotoxic myopathy, periodic paralysis, myasthenia gravis, and ophthalmoplegia. (7) The only symptoms of hyperthyroidism and thyroid function is not high by 1. People (drug-induced) hyperthyroidism 2. Thyroiditis subacute thyroiditis with hyperthyroidism chronic lymphocytic thyroiditis (Hashimoto's thyroiditis), if the early stage hyperthyroidism called thyroid function temporarily radioactive Hashimoto thyroiditis with hyperthyroidism Development of bone fibrous dysplasia in with hyperthyroidism. Clinical clinical manifestations is a very common endocrine diseases. Means from all causes increased thyroid function, thyroid hormone secretion or because of too much thyroid hormone (T3, T4) levels increased in the blood caused by the body the nervous system, circulatory system, digestive system, cardiovascular system, a multi- series of high metabolic syndrome and high-excitement symptoms and eye symptoms. Palpitation, tachycardia, heat intolerance, sweating, appetite, hyperactivity, weight loss, weight loss, fatigue, weakness and emotional irritability, brash, insomnia, distracted, proptosis, tongue, hand tremors, goiter, or enlargement, female may have menstrual disorders or amenorrhea, men may have impotence or breast development. Goiter was symmetrical, and some patients with non-symmetrical enlargement, goiter, or enlargement will move up and down with swallowing, but also part of the hyperthyroid patients with thyroid nodules. First, the nervous system in patients with irritability, mental allergy, second-hand flat on the tongue and when to move out fine tremor, say more hyperactivity, insomnia, nervous, distracted, anxiety, irritability, and so much suspicion, and sometimes hallucinations, even Asian mania, but there are reticent, depression, patients active tendon reflexes, reflex time shortened. Second, the high heat intolerance in patients with metabolic syndrome, sweating, often fever, crisis may have a high fever, heart palpitations more than a pulse rate, appetite was hyperactivity, but the weight loss, fatigue, weakness. Third, mostly diffuse symmetric enlargement of goiter, a small number of asymmetric, or swelling significantly. Thyroid blood flow also increased, can be heard up and down the outside leaves and vascular murmur and palpable thrill, especially in the upper part of the gland was. It is characteristic of this sign, is important in diagnosis. Fourth, sub-invasive eye symptoms and non-invasive exophthalmos exophthalmos exophthalmos latter also known as benign, the patient exophthalmos, eye gaze or eyes showed panic; the former said malignant exophthalmos, proptosis changes can be made benign and malignant exophthalmos were often sensitive to light, tearing, diplopia, vision loss, eye swelling, irritation, foreign body sensation, etc., due to a high degree of prominent eye, the eye is not closed, the conjunctiva, cornea exposed caused congestion, edema, corneal ulcers and even blindness. And some patients with hyperthyroidism without eye symptoms or symptoms not obvious. V. v. the cardiovascular system, heart palpitations, shortness of breath, a little activity is significantly increased. Often tachycardia (mostly the sinus), cardiac arrhythmia, cardiac hypertrophy, expansion and severe congestive heart failure, and there are arrhythmias, heart enlargement, heart failure and other serious performance, there are also reports of sudden ventricular fibrillation. Sixth, the digestive system hyperactivity appetite, body weight was significantly decreased, with the two tips of the disease or diabetes often possible. Too much thyroid hormone can increase stool frequency so excited bowel movements, sometimes due to fat malabsorption in celiac sprue Erzhi thyroid hormone has a direct toxic effect of the liver caused by hepatomegaly and BSP retention, GPT increased and so on. VII, blood and hematopoietic system of the disease around the hematoma, the total number of low WBC, lymphocyte percentage and absolute and mononucleosis, platelet life span is shorter, and sometimes purpura syndrome can occur, due to increasing consumption, malnutrition and iron utilization barriers can cause anemia. Eight, mainly for muscle motor system weakness, a few visible thyrotoxic myopathy. IX, female reproductive system, menstrual reduction cycle is lengthened or amenorrhea. However, some patients can pregnancy, childbirth. Male impotence. Ten, skin and extremities in some patients and the typical small symmetry myxedema, but not hypothyroidism, usually in the lower leg tibialis anterior, and sometimes also found in dorsal and knee, upper face and head. Beginning of the dark red skin lesions, flaky skin, thick or nodular later folded, and finally was dendritic, may be associated with secondary infection, and pigmentation. Can be seen in a few patients showed soft tissue swelling finger clubbing type, metacarpal and phalangeal subperiosteal new bone formation, and the means or the free edge near the nail bed and a separate phenomenon, known as the tip of finger thick. XI, the endocrine system to excessive secretion of thyroid hormone addition to affecting gonadal function, adrenal cortex function in the early stage of the disease often more active, and in severe (such as the crisis) patients, the relative decline of its functions, or incomplete; increase in pituitary ACTH and plasma cortisol levels were normal, but the clearance rate of acceleration, transport and use on its faster. Ocular changes caused by hyperthyroidism. Typical auxiliary examination in patients with hyperthyroidism, with clinical symptoms and signs to confirm the diagnosis. Or illness is not typical for patients with more complex, you need to be made by laboratory diagnosis. Many patients with hyperthyroidism inspection items, each check has some clinical significance. Each patient according to different circumstances, select some items targeted examination is very important. Hyperthyroidism Checklist (1) to understand the status of the project metabolism: basal metabolic rate (BMR); Determination of blood cholesterol, triglycerides, and urinary creatine determination. (2) to understand the level of serum thyroid hormones projects: serum total T3 (TT3) determination of serum total T4 (TT4) determination of serum free T3 (FT3) determination of serum free T4 (FT4) measured serum anti-T3 (rT3) determination . (3) the pituitary - thyroid axis adjustment of the project: rates of thyroid uptake of iodine 131 and thyroid suppression test (including the T3 suppression test and thyroid tablets inhibition test), serum high sensitive determination of thyroid stimulating hormone (S-TSH), thyroid stimulating hormone releasing hormone stimulation test (TRH stimulation test). (4) to understand the situation of goiter Project: B-mode ultrasound examination of thyroid, thyroid radionuclide imaging examination. (5) thyroid immunological tests: determination of thyrotropin receptor antibody, such as thyroid stimulating immunoglobulin (TRAb), etc.; thyroglobulin antibody (TGAb); thyroid microsomal antibody (TMAb) or anti-thyroid peroxide matter antibody (TPOAb) determined. (6) Understanding the nature of the project of thyroid disease (7) Check the electrolyte differential diagnosis differential diagnosis of the situation to be considered: simple goiter. In addition to goiter, there are no such signs and symptoms. Although sometimes increased 131I uptake, T3 inhibited sexual inhibition test most of the show. Serum T3, rT3 were normal. neurosis. own high functioning thyroid nodule, the scan focused on the tubercle radioactive: The scan was repeated after TSH stimulation, visible nodules increased radioactivity. other. Tuberculosis and rheumatism are often low heat, sweating tachycardia, in order to diarrhea as the main performers often misdiagnosed as chronic colitis. Show more elderly is not typical of hyperthyroidism, often indifferent, anorexia, significant weight loss, was misdiagnosed as cancer. Unilateral infiltrative exophthalmos with orbital and cranial to be low tumors. Myopathy associated with hyperthyroidism, the need to familial periodic paralysis and myasthenia gravis identification. Complications 1, hyperthyroidism type 16 to 73 years can be heart disease, the incidence rate of 13.4% in patients with hyperthyroidism 21.8%, and often occur in hyperthyroidism after 2 to 3 years, in addition to typical clinical manifestations of hyperthyroidism, the ECG often sinus tachycardia, atrial fibrillation, atrial flutter, atrioventricular block, ventricular contractions, myocardial injury and cardiac hypertrophy. Enlarged heart and aortic valve type can be presented, or around the heart to expand type. Along with heart disease can be cured of hyperthyroidism improved, the disease often should myocarditis, coronary heart disease, rheumatic heart disease and other diseases, diagnosis of heart enlargement. 2, hyperthyroidism periodic paralysis of the disease mostly occurs in young men who, often mixed with thyrotoxic myopathy thyrotoxic myopathy serum potassium normal and abnormal EMG, and there were periodic paralysis with hyperthyroidism: potassium <3.5mmol / L, Department of potassium metabolism; abnormal distribution of potassium: Potassium blood sugar can make the relocation of the cells from the cells; enhance the excitability of the central nervous system, vagus nerve to promote an increase in insulin release after further exception for the distribution of potassium ; immune factors can cause IATS, LATS-P, T3 and T4 levels, etc., reduce the level of thyroid hormone for potassium; high adrenergic state of hyperthyroidism may promote reduction in the level of potassium thyrotoxic periodic paralysis occurs. Barth syndrome should be the type (Bartters syndrome), familial periodic paralysis, hypomagnesemia, hyperaldosteronism, myasthenia gravis and the identification of drug-induced hypokalemia. 3, total incidence of hyperthyroidism thyroid crisis-type 1% to 2%, the elderly were more common, often associated with infection, trauma, surgery, childbirth, overwork, sudden withdrawal, and incidence of drug reactions and other such factors, resulting hyperthyroidism increased sympathetic nerve activity to enhance the roles Erzhi crisis. Pre-crisis to heat up to above 39 , pulse rate of 120 ~ 160 times / min, irritability, loss of appetite, nausea, vomiting, diarrhea, trance, more than sweat, drowsiness, coma and developed to semi-coma. Crisis that coma patients have been very dangerous. Leukocytosis, abnormal liver function, GPT, GOT, bilirubin, etc. can be increased, may have dehydration, low blood pressure, electrolyte imbalance, acidosis, heart failure and pulmonary edema. Serum T3, T4, FT3, FT4 may be increased, high mortality, have local and timely rescue. Medical treatment of drug treatment (a) in the treatment methods and indications, including anti-thyroid drug therapy, adjuvant therapy and enhancing the lives of nutrition therapy. Anti-thyroid drugs for Thiourea-based, this method is the main method of medical treatment. Adjuvant therapy is mainly used propranolol, reserpine and other symptomatic treatment. Life treatment is proper rest, nutrition and diet with sufficient calories, including sugar, protein, fat and B vitamins, etc., and avoid mental stimulation and fatigue. Drug treatment using thiourea drugs inhibit organic iodine in the thyroid gland to reduce thyroid hormone synthesis, but the medicines do not inhibit thyroid iodide uptake and release of hormones have been synthesized, the onset of treatment should be added with -blockers, such as propranolol, metoprolol and so on. But it must be long-term use, usually in about one and a half to two years to gradually reduce the dosage and to the withdrawal do not. However, about one-third to half of patients relapse, especially those neck larger or more of the patients dietary intake of iodine (such as eat kelp, seaweed, iodized salt). In addition, the small number of patients taking the first two or three months, will occur itching, rash, or leukopenia (easy to fever, sore throat), hepatic dysfunction drugs such as allergy. If these phenomena occur, should consult a doctor immediately for further diagnosis and treatment. Indications for drug treatment: light condition, the smaller Graves hyperthyroidism thyroid; younger (under 20 years of age), pregnant women, frail or with severe liver, kidney or heart disease should not be surgery; surgery preparation; without recurrence after surgery is preferable to isotope treatment; radioisotope therapy as adjuvant therapy. (B) in the treatment of hyperthyroidism side effects of antithyroid drugs antithyroid drug treatment of hyperthyroidism: propylthiouracil, methimazole can cause leukopenia, etc., generally occurs in the first few months after treatment, such as the timely withdrawal, mostly in 1 to 2 weeks recovery, so the medication should be regularly checked during the blood. That medical treatment of hyperthyroidism in antithyroid drug therapy is the most serious side effects Leukopenia, agranulocytosis, neutropenia as too little systemic resistance decreased significantly, and then lead to serious systemic infection, a great threat to life. Therefore, whether the drug should pay attention during agranulocytosis occurrence, if in time, but also more chance of cure. Agranulocytosis occurred more in the drug l-3 months, but can also be found at any time after treatment. Therefore, in the drug l-3 should be especially vigilant during the month. Incidence of agranulocytosis in two ways, one is sudden, generally can not prevent. The other is gradual, usually first, neutropenia, if it continues to medication, can be converted to agranulocytosis. In the latter disease, it can be regularly checked during the treatment by white blood cells to prevent. During the treatment, you can check 1 week white blood cells, white blood cell count if less than 3 10 ^ 9 / l, generally observed to be discontinued, if the white blood cell count in the 3-4 10 ^ 9 / l, should be every 1 - Charles 1 3 days, and drugs such as with a rising white blood leucogen, turtle liver alcohol, use of hormone therapy when necessary, it is best for the other kind of anti-thyroid drug treatment through the above measures, leukocytes still down, you need to stop with anti-thyroid drugs, use other methods of treatment of hyperthyroidism. Agranulocytosis in the event, should immediately stop using anti-thyroid drugs, and sent to hospital for emergency treatment. Resistance is too weak because the patients should be rescued in a sterile isolation ward and give a lot of glucocorticoid hormones and antibiotics. Cured the patient can no longer anti-thyroid drug therapy of hyperthyroidism. (4) The patients with hyperthyroidism or hypothyroidism can lead a normal sex life issues. Patients with hyperthyroidism or hypothyroidism can lead a normal sex life to be according to disease conditions. In general, patients with mild or moderate and severe lesions after treatment of patients under control, the symptoms disappeared, the patient tends to feature a variety of normal life activities, you can have sex sparingly. But the following questions should draw attention to: patients with hyperthyroidism have a wide range of neurological symptoms such as irritability, paranoia, irritability, fear, anxiety, etc.; autonomic nervous excitability enhancement, there palpitation, cardiac arrhythmias. In addition, neuromuscular disorders, trembling limbs, weakness. Sexual excitement can often induce or aggravate these symptoms. Some patients with hyperthyroidism and hypothyroidism due to loss of libido, impotence and other serious impact on the sexual harmony between husband and wife can not carry out normal sexual life, must be actively targeted therapy, the recovery of sexual function. patients with hyperthyroidism often irregular menstrual cycle, many for extended periods, but there are shortening who have less menstrual flow, or amenorrhea. Therefore, very little chance of conceiving. If pregnancy occurs more chance of miscarriage. Spermatogenesis in male patients due to the inhibition showed azoospermia azoospermia or less, must also be aggressive treatment for the cause in order to achieve growth objectives. hyperthyroidism patient's condition is stable, that is, the clinical status over treatment of the basic control, three serum total triiodothyronine (T3) or four iodine thyroid gland of the original acid (T4) were normal, the normal rate of thyroid uptake of iodine level (2 hours and 4% -30%, 24 hours 25-65%), withdrawal over six months, generally lead a normal sex life. Often easy to make the sex life or increase relapse of hyperthyroidism, some patients taking more than 1 year after discontinuation, still about 1/2-1/3 of a relapse, so the sex life of the restoration must be conducted under the supervision of doctors. patients with hyperthyroidism taking a long time, the service's drugs such as methimazole, -physical blockers, reserpine, guanethidine, which have teratogenic effects. Therefore, in order to avoid drug-induced birth defects, can resume sexual activity after pregnancy, to accept the physician's guidance. Surgical treatment (a) in the treatment methods and indications recurrence after subtotal thyroidectomy is low, but the surgery is irreversible destructive treatment, and can cause some complications, should be carefully chosen. Indications as follows: in severe hyperthyroidism, long-term medication is invalid, withdrawal relapse, long-term medication or can not unwilling; thyroid symptoms, large or there is oppression; substernal goiter with hyperthyroidism; nodular goiter with hyperthyroidism. Were not suitable for surgical treatment are: infiltrative exophthalmos were; serious heart, liver, kidney, lung complications and poor general condition who can not tolerate surgery; early pregnancy (first 3 months) and late (after 3 months); mild drug treatment of patients is expected to be remission. (B) the status of surgical treatment of subtotal thyroidectomy is the treatment of hyperthyroidism is still a common and effective method. Hyperthyroidism with antithyroid drugs can not cure, it can not replace surgery. According to statistics, simply to cases of anti-thyroid drugs, about 50% could not return to work, while the cases treated by surgery, only 5%. Therefore, if the application of anti-thyroid drug treatment for 4 to 5 months after the effect can not be consolidated, should consider surgery. For surgical treatment, in addition to young patients, less severe and accompanied by other serious diseases were not surgery, but may be surgery. For the secondary hyperthyroidism and high functioning adenomas, using anti-thyroid drugs or the effect of 131 iodine therapy are not very significant, as well as malignant transformation may also wish to use surgical treatment. Has been complicated by left ventricular expansion, arrhythmia and even cardiac arrhythmia, and even more should be surgery, before they can be cured. Attempt to cure the cardiac symptoms, then surgical solution is cart before the horse, but exacerbate the condition. For pregnant women, as hyperthyroidism can cause adverse effects on pregnancy, causing miscarriage, premature birth, fetal death, pregnancy, toxic psychosis; pregnancy and may exacerbate hyperthyroidism. Therefore, pregnancy pregnancy early, middle, or 4 to 6 months, surgical treatment should be considered; to the late, hyperthyroidism and pregnancy has little interaction between, you can be treated by operation after childbirth. (C) of the preoperative preparation and the importance of: basal metabolic rate of hyperthyroid patients with high-pitched in the case, the operative risk is high. Therefore, the full and complete preoperative preparation and its importance. 1. First, the idea to do the work of the patient, eliminating the patient's concerns and fears. Mental stress, anxiety and insomnia may be given sedatives and sleeping pills. Heart failure has occurred, shall be given digoxin preparations; associated with atrial fibrillation who can give propranolol or quinidine treatment. 2. Preoperative examination: In addition to a comprehensive physical examination should also include: measured basal metabolic rate, T3T4 check and 131 iodine uptake test. In patients with increased regularly re. laryngoscopy to determine the vocal cord function. ECG and detailed examination of whether the expansion of the heart, such as noise or irregular heartbeat. a substernal goiter, should do the neck X-ray and contrast swallow at the same time the patient to determine the compression level of the trachea and esophagus. 3. Drug preparation: lower basal metabolic rate is an important part of preoperative preparation. If the patient is basal metabolic rate, can be used thiouracil drugs (methyl or propylthiouracil, methimazole, etc.). These drugs can stop the process of organic iodine, the oxidation of iodine can not be combined with tyrosine. In addition, its is also the hydrolysates of thyroid peroxidase, can effectively prevent the synthesis of thyroid hormone and thyroid lymphocytes are important for immune function, due to thiouracil-type drugs can goiter and arterial congestion, surgery prone to bleeding time, increase the difficulties and dangers of surgery. Therefore, taking drugs PTU must be added with iodine after. The basic control symptoms of hyperthyroidism, you can switch to oral iodine solution (lugol's solution), 3 times a day orally, starting from the 3 drops, 1 drop per day increments, to 16 drops only to maintain this amount 3 ~ 5 days. Iodine on the thyroid gland hyperplasia of the state role is in the first 24 to 48 hours to block the normal aspects of organic iodine, thyroglobulin block hydrolysis, thereby inhibiting the release of thyroid hormone, so that degradation of the follicular cells, thyroid blood flow reduction brittleness decreased. Therefore reduce the hardening gland, thus contributing to thyroid surgery. For the routine application of iodine or in combination with anti-thyroid drugs can not tolerate or can not afford a significant role in the case of iodine and propranolol can be combined with preoperative propranolol dose administered once every 6 hours, orally, every time 40 to 60 mg. Propranolol half-life of 3 to 6 hours. Therefore, the last time of oral propranolol in 1 to 2 hours before surgery; without atropine before surgery in order to avoid tachycardia. Following the service propranolol after 4 to 7 days. Propranolol is a -blocker, you can choose the target tissue of the -receptor blockade on the role of catecholamines, inhibition of adrenergic activity increase, reducing the effect of surrounding tissue of the thyroid hormone, so symptoms of hyperthyroidism improved. Propranolol did not inhibit thyroid hormone release. In recent years, some people advocate a single hard De entirely preoperative preparation for hyperthyroidism. Advantages: one can shorten the preparation time before surgery, on the other hand does not affect thyroid function, thyroid surgery immediately understand the function of residual part of the state. However, most scholars believe that: The indications for propranolol should be limited to the above-mentioned cases, that is, can not afford significant effect on the iodine case, and should still be combined with iodine, a single hard De entirely for high-functioning adenomas only preoperative preparation of patients. (D) operation time: by the drugs for 2-3 weeks. Basic control symptoms of hyperthyroidism (patients with emotional stability, improved sleep, weight gain), pulse rate remained stable at 90 times per minute, less, early, middle and late pulse rate fluctuations less than 10 beats / min, basal metabolic rate of +20% or less or T3T4 value in the normal range. Reduce the hardening gland, vascular noise reduction surgery can be done. Need to show that "the appropriate timing of surgery," It is true generally close to the normal basal metabolic rate to determine whether or not, but not completely as the standard, should also refer to the body, particularly the improvement of the circulatory system. Reduction in pulse rate, pulse pressure returned to normal and so on, is often an important indicator of appropriate timing of surgery. (E) points subtotal thyroidectomy: 1, anesthesia: local anesthesia in most cases works well, and can keep abreast of vocal cord function, to avoid the recurrent laryngeal nerve injury. If severe tracheal compression or large substernal goiter, in order to ensure the smooth operation of the respiratory tract, reduce the burden on the heart, you should consider endotracheal anesthesia. 2, the operation should be gentle, meticulous, every step taken seriously. from the edge of the sternum Wang pointed to do the two incision under the various cross-sectional or separated hyoid muscle, into the thyroid capsule and intrinsic membrane outer space, can be isolated from the thyroid body. to fully expose the thyroid gland. Ligation, cutting off the superior thyroid artery and vein Ying close to the upper pole of the thyroid to avoid injury in the superior laryngeal nerve, such as to ligation of the inferior thyroid artery, to try to leave the glands on the back, near the common carotid artery ligation of the inferior thyroid artery. This not only avoids the recurrent laryngeal nerve injury, and the branches of the inferior thyroid artery is still with the larynx, trachea, pharynx, esophagus arterial branches remain consistent with each other, will not affect the remaining part of thyroid resection and parathyroid blood supply. the amount of removal of the gland, hyperthyroidism should be based on the size and extent of the thyroid, and generally require removal of the gland in 80 to 90%, each side of the left thumb distal glands to adult size as appropriate. Glands removed easily lead to recurrence of too little, too much also prone to hypothyroidism. In addition, the back part of the gland must be preserved, not only can avoid the recurrent laryngeal nerve injury, and avoid damage to parathyroid glands. Thyroid isthmus should also be removed. surgery to hemostasis, and for larger vessels (such as the thyroid artery and vein, thyroid gland, vein) should be double ligation, respectively, to prevent slippage bleeding. Unobstructed drainage incision should be set 24 to 48 hours to drain the bleeding time, the neck of the space, the product of a small amount of blood can be compression of the trachea. 3, and postoperative observation and care, patients pay close attention to breathing, body temperature, pulse, blood pressure changes. Potassium iodide solution after continued use of compound, 3 times a day starting from 16 drops, 1 drop daily successive reduction. Such as the combination of preoperative propranolol for preoperative preparation and postoperative propranolol following the service from 4 to 7 days. Semi-supine patients should take to facilitate breathing and wound drainage. Help the patient expectoration, bedside tracheotomy package and place the gloves to suffocation in a timely manner in case the patient did tracheotomy. (F) The main complications were: 1, postoperative respiratory difficulties and asphyxia: This is the most critical postoperative complications occurred within 48 hours after surgery. Common cause of bleeding wound for the compression of the trachea . Major surgery to stop bleeding is not complete, or caused by vascular ligature slippage. laryngeal edema. Mainly due to operative trauma or injury caused by intubation. tracheal collapse. Is a long-term tracheal pressure, the occurrence of softening, after losing support of the surrounding tissue caused. Clinical manifestations of dyspnea, irritability, cyanosis and even suffocation. Such as those caused by bleeding, there are neck swelling, drainage and other mouth oozing blood. If this happens, immediately at the bedside suture, open wounds, removal of hematoma; if the situation does not improve, tracheotomy should be done immediately, be patient improved, sending the operating room for further examination processing. Hyperthyroidism thyroid hormone levels over the physiological role of insulin more antagonistic, and can promote intestinal absorption of glucose and promoting gluconeogenesis, thus causing hyperglycemia, leading to diabetes.


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