Persistent low TSH with high T3 and T4

[Faebinder]

So I have a patient with classic SCPT who persistantly keeps getting readmitted and has low TSH with high T4 and borderline high T3. Of course homeless and will never follow-up as an outpatient for his abnormal thyroid. Hospitalists are getting mad now a days for mini consults in this branch of the hospital.

Is there anything else you can do in the inpatient setting for these cases?

I was debating sending him for a thyroid ultrasound. Any suggestions?

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[michaelrack]

Back in the days when I was a primary care doc, we used to do radioactive iodine scans of hyperthyroid patients. Based on the results of the scan, using an algorithm, the radiologist would in most cases ablate the patients using higher doses of radioactive iodine. I am not sure if this would be helpful in your case, however, since, the patient would need close f/u of his thyroid status and would probably need thyroid hormone replacement after the ablation.

One thing you could do is prescribe a beta blocker, which controls some of the symptoms of hyperthyroidism. Also, I believe that propanolol has a minor effect of preventing the conversion of thyroid hormone to the active state.

I think a thyroid US would be less helpful than a nuclear scan. Can you consult an endocrinologist when he is an inpt?

 

[Faebinder]

Back in the days when I was a primary care doc, we used to do radioactive iodine scans of hyperthyroid patients. Based on the results of the scan, using an algorithm, the radiologist would in most cases ablate the patients using higher doses of radioactive iodine. I am not sure if this would be helpful in your case, however, since, the patient would need close f/u of his thyroid status and would probably need thyroid hormone replacement after the ablation.

One thing you could do is prescribe a beta blocker, which controls some of the symptoms of hyperthyroidism. Also, I believe that propanolol has a minor effect of preventing the conversion of thyroid hormone to the active state.

I think a thyroid US would be less helpful than a nuclear scan. Can you consult an endocrinologist when he is an inpt?

I can, but you know doing a weekend consult for an endocrinologist in this branch of the hospital is like asking for the a congressman to call you back in the weekend. In addition, consults of subspecialties of medicine gotta go through hospitalist first as per rules. Worse, the inpatient unit I am in right now has limited number of days per patient. It's "treat & street" or send to a state hospital... no middle ground.

I'm gonna see if I can get a thyroid nuclear scan over the weekend. Thanks for the tip.

 

[whopper]

Faebinder, you know I graduated from the same place so I think I know what I'm talking about.

One of the hospitalists (Dr. R) is a prick. I don't mind saying it now becuase I'm an attending & on his level. I had a patient who had chest pain, several RFs for heart disease & an abnormal EKG and Dr. R still wouldn't see him. It got to the point where the hospital management were informed because of the severity of the situation--he finally showed up, all steaming mad. (Though some of them are very good such as Dr. Zampino & Dr. Sun.). Unfortuantely Dr. R is often assigned to cover the psyche unit.

I wouldn't be surprised if Dr. R did everything in his power to not see your patient. As for endocrinologists, since there's a shortage of them over there, its a general policy that the patient can only be referred on an outpatient basis to see an endocrinologist.

Your best bet is you're going to have to stabilize the patient, and if ready for outpatient, refer to an endocrinologist. Personally, I'd reccomend if possible to refer the patient to the day-program across the street. From there, they'll make sure the patient sees the endocrinologist. If you can't get the patient stable, then the patient will have to be referred to Ancora, where that patient will be seen by an internal medicine doctor who'll handle the endocrine end.

You should also ask your attending what to do & leave it on his end. Whenever politics occur between depts especially when attendings need to be involved, it should not be a resident making the demands, it should be an attending.

If that pt does not go for further workup, and its to the point where they're not commitable, you have no choice in the matter. Its common in psychiatry for several of our patients to not treat their physical illness despite our reccomendations.

For all of you not from my program, its split into 2 locations. One is a unversity hospital, where this type of political bull wouldn't have happened. The other is a community hospital where unfortunately, this type of thing happens all the time. The hospitalists don't want to handle the medical end of the patient unless its an extreme emergency, however several things can happen with the psyche patients that aren't exactly an emergency, but require medical care. While its frustrating, this happens in all community hospitals, & IMHO was good training to be able to see both sides.

 

[Faebinder]

Thanks Whopper. Fully agree with your comments about the hospitalists here BTW. Thanks for the tip about the day program. I didn't realize they might potentially make em see an endocrinologist.

Michael's tip about propanolol is cool. If I can tone down that hyperthyroidism a little, he might stabilize faster.

I highly doubt this guy will ever followup on it.. homeless/noncompliant and what not but we dont treat people according to what they might do. Well you know how it works... you cant force treatments down people's throat but sometime people do listen.

 

[whopper]

While the unit is short term & does "treat & street", don't factor out that we do refer to outpatient.

When you're working there in your first year, you don't see the treatment that goes on afterwards. The day program is pretty much just as intense as inpatient minus that the patients go home at night, and aren't seen on weekends. The attending there, Dr. Lujan is excellent. I've had several patients in the day program, where the program made sure they got their medical treatments. They even drove them to the doc's office.

Also, the PACT team is very good.

You don't start seeing these things till 3rd year, so in your first year, it gives you an impression that we're not doing everything we can. The system's designed so that there's several layers. Short term inpatient is only one of those layers.

Tell Dr. Zampino, Tufail, Sun, and the psychiatrists I say hi.

 

[primadonna22274]

Thyroid US will tell you if there are thyroid-secreting nodules driving the hyperthyroidism but doesn't help you if negative. Thyroid uptake scan will help you the most (agree) and you should be able to get it easily enough inpatient. Results of the scan will help guide treatment. Any possibility of just consulting endocrine? I agree, difficult case given your limitations and patient compliance which will be a bear. Agree with B-blockade for symptoms if present (tremulousness, tachycardia, anxiety). Won't help if he lacks those symptoms although I suppose those symptoms could be masked by whatever psychotropics he's appropriately on.
Good luck
Lisa (primary care PA)