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Year 3 OSCE > Case 7- Thyroid Disease > Flashcards

Case 7- Thyroid Disease Flashcards

1
Q

Graves ophthalmology features

A

Exophthalmos (proptosis)- anterior bulging of the eye out of the orbit
Opthalmoplegia
Conjunctival oedema
Upper eyelid retraction and lag
Inability to close eyelid

Give topical lubricants, steroids

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2
Q

Unique features of Graves’ disease

A

Diffuse goitre (no nodules)
Graves eye disease
Pretibial myxoedema
Thyroid acropachy (clubbing, soft tissue swelling, periostea new bone formation)

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3
Q

Investigations for Graves disease

A

Physical thyroid exam
Eye exam if opthalmopathy present
FBC- exclude infection (tachycardia/ sweating), UE, TFT
Thyroid antibodies and calcitonin/thyroglobulin markers- TRAb (exclude medullary, papillary and follicular thyroid cancer)
Thyroid ultrasound with FNA- if TRAbs low?
Radioactive iodine uptake (diffuse, homogenous, increased uptake)

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4
Q

Graves’ disease antibodies

A

TRAb- specific
Anti TPO- non specific
Anti Tg- non specific

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5
Q

Treatment of a Thyrotoxic storm

A

BLAH
Beta blocker (propranolol)
Lugols iodine
Anti thyroid drugs/thionamides (PTU)
Hydrocortisone

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6
Q

Hashimoto’s thyroiditis antibodies

A

Anti TPO
Anti Tg

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7
Q

Difference between Hashimotos and de Quervains

A

H- autoimmune, rarely hyperthyroid beforehand, and if it is present it is prolonged
DQ- viral infection (also painful/raised ESR), short initial hyperthyroid period

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8
Q

Horner syndrome

A

Miosis
Partial ptosis
Facial anhidrosis

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9
Q

Sx hyperthyroidism

A

Heat intolerance, sweating, weight loss, palpitations, tremor, tachycardia, goitre, irritability, onchylosis, oligomenorrhoea, decreased libido, graves specific features

NB- high output cardiac failure in the elderly

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10
Q

Graves differentials

A

TMG, thyroiditis

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11
Q

Sx hypothyroidism

A

Tiredness, lethargy, low mood, cold intolerance, increased weight, constipation, menorrhagia, hoarse voice, memory/cognitive impairment, myalgia, cramps, weakness, coarse hair, dry skin, expressionless face, rounded face, reflexes slow to relax, hair loss (lateral edge eyebrows), carpal tunnel syndrome

NB- hyperlipidaemia

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12
Q

Thyroid cancer Sx

A

Painless, palpable thyroid nodule (no Sx of hyperthyroidism or hypothyroidism)

Advanced symptoms include;
Hoarseness, dyspnoea, dysphagia, cervical lymphadenopathy, tracheal deviation, Horner syndrome

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13
Q

Thyroid nodule investigations

A

Thyroid exam
FBC UE- see if fit for surgery, exclude infection, Ca (spread to bone)
TFT’s (unchanged in cancer- cold nodules)
Tumour markers or thyroid antibodies- calcitonin (medullary carcinoma) thyroglobulin (follicular/ papillary)
Ultrasound scan (gold standard) and FNA
Thyroid scintigraphy (radioiodine uptake- cold nodules are malignant)
Staging- CXR, HEAD, NECK CT SCAN

NB- remember the markers and cancer types as: MC TFP

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14
Q

Hashimoto’s thyroiditis

A

Features of hypothyroidism (rarely preceded by a thyrotoxicosis phase where the thyroid hormone is dumped out- causes a diffuse, lumpy painless goitre and hyperthyroidism Sx, but only in rare circumstances and lasts for several months, unlike de Quervain’s hyperthyroid period which only lasts a few weeks)

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15
Q

De Quervains Thyroiditis

A

AKA- subacute thyroiditis

Triphasic pattern- very short period of hyperthyroidism, then hypothyroidism, then back to euthyroidism

Usually a self limiting viral infection (normally only needs aspirin- steroids in severe cases)

Painful goitre, raised ESR
Thyroid scintigraphy- global reduced uptake of iodine 131

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16
Q

Post partum thyroiditis

A

First hyperthyroid
Then hypothyroid
Then back to euthyroid (within a year)

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17
Q

Sub clinical disease

A

Sub clinical hypothyroidism- raised TSH, normal T3/4

Sub clinical hyperthyroidism- low TSH, normal T3/4

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18
Q

Secondary hyperthyroidism

A

TSH secreting adenoma (different set of results)

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19
Q

Secondary hypothyroidism

A

Pituitary/ hypothalamic failure

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20
Q

T4 vs T3

A

Free T4 is better to monitor- more of it (a lot of T3 produced from T4 (peripheral conversion))

BUT- T3 is the active hormone

21
Q

FNA and cytology of thyroid nodules

A

Thy1- do again
Thy2- benign
Thy3- intermediate
Thy4- suspicious of malignancy
Thy5- diagnostic of malignant

22
Q

Radioiodine outcomes

A

Malignancy- cold nodule

Graves- increased uptake diffusely

TMG- mixed hot and cold nodules (patchy)

Toxic adenoma- 1 hot nodule

Thyroiditis- reduces uptake

23
Q

Hyperthyroidism treatment regimens

A

Carbimazole can either be titrated to maintain normal levels (titration block)- more suitable as done over a longer term and suitable in pregnancy (other one isn’t)

Or

The dose blocks all production of thyroid hormone, and then takes levothyroxine until they are euthyroid (block and replace)

24
Q

Management of Graves’ disease

A

Graves’ disease patients should be referred to secondary care
Beta blocker
ATD- carbimazole (12-18 months)
Radioiodine treatment (relapse or resistant to ATD therapy)
Thyroidectomy

25
Q

Management of hypothyroidism

A

Levothyroxine (cardiotoxicity- cardiac ischaemia/ AF, be careful)
Regular monitoring

26
Q

Papillary cancer

A

Most common
Good prognosis, although spreads early
Thyroglobulin
Young women

27
Q

Follicular carcinoma

A

Encapsulated
Second most common
Thyroglobulin

28
Q

Medullary carcinoma

A

Third most common
Calcitonin often raised
MEN2- family history, symptoms of pheochromocytoma

M for M (MEN and Medullary)

29
Q

Anaplastic carcinoma

A

Rare
Old women
Poor prognosis as treatment resistant and frequently invades

30
Q

Carbimazole MOA

A

Blocks thyroid peroxidase from coupling and iodinating tyrosine residues on thyroglobulin

Associated with agranulocytosis- sore throat

31
Q

Contraindications to radio iodine treatment

A

Pregnancy (avoid 4-6 months following)
Below 16

NB- many will require thyroxine 5 years after treatment

32
Q

Associations of Hashimoto’s thyroiditis

A

Autoimmune conditions eg. Coeliac disease, T1DM
MALT lymphoma

33
Q

Amiodarone and the thyroid gland

A

Can cause hypothyroidism and hyperthyroidism

continue in hypo, stop in hyper (can use either carbimazole/steroids/potassium perchlorate)

34
Q

Rare secondary causes of hypothyroidism

A

Pituitary failure
Down’s syndrome

35
Q

Rare primary causes of hypothyroidism

A

Iodine deficiency
Lithium

36
Q

Side effects of levothyroxine therapy

A

Hyperthyroidism (over treatment)
Reduced bone mineral density
Worsening of angina
AF

Interacts with iron and calcium carbonate (absorption reduced, so give at least 4 hours apart)

37
Q

Myxoedema coma

A

Typically presents with confusion and hypothermia

IV thyroid replacement and fluids
IV corticosteroids

38
Q

ATD’s in pregnancy

A

Propylthiouracil in 1st trimester
Carbimazole in 2nd and 3rd
No radioiodine

39
Q

Hypothyroidism and pregnancy

A

Thyroxine is safe
Increase thyroxine by 50% as early as 4-6 weeks pregnancy

40
Q

Sick euthyroid syndrome

A

Low T3 and T4 (thyroxine)
Normal TSH
No treatment needed

41
Q

Subclinical hyperthyroidism

A

Normal T3 and T4
Low TSH

Usually untreated but can offer low dose ATD for 6 months

42
Q

Subclinical Thyroid Disease

A

Subclinical Hypothyroidism

TSH raised but T3, T4 normal

-consider offering levothyroxine if the TSH level is > 10 mU/L on 2 separate occasions 3 months apart
-if < 65 years consider offering a 6-month trial of levothyroxine if:
the TSH level is 5.5 - 10mU/L on 2 separate occasions 3 months apart, and there are symptoms of hypothyroidism
in older people (especially those aged over 80 years) follow a ‘watch and wait’ strategy is often used
if asymptomatic people, observe and repeat thyroid function in 6 months

Subclinical Hyperthyroidism

a therapeutic trial of low-dose ant thyroid agents for approximately 6 months in an effort to induce a remission

43
Q

Most common cause of hypothyroidism

A

Developed world- Hashimoto’s
Undeveloped world- iodine deficiency

44
Q

Poor thyroxine compliance biochemistry

A

High TSH
Normal T4 (TSH lags behind if patient has just taken thyroxine in recent days)

45
Q

Management of a TMG

A

Radioiodine therapy

46
Q

What marker is used to guide treatment success in hypothyroidism?

A

TSH

47
Q

Grading Graves ophthalmology

A

The severity of Grave’s eye disease can be graded using the mnemonic NOSPECS

No signs / symptoms
Only signs (e.g: upper lid retraction)
Signs & symptoms (including soft-tissue involvement)
Proptosis
Extra-ocular muscle involvement
Corneal involvement
Sight loss due to optic nerve involvement

48
Q

Thyroglossal cyst

A

Reassure- no surgery

Year 3 OSCE (61 decks)

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