clinical thyroid disease

Question 1

describe the anatomy of the thyroid and parathyroid glands?

Answer 1

Question 2

describe the primary and secondary feeback loop of the thyroid?

Answer 2

Question 3

what questions would you want to ask

55 year old female,
Reports 6 months of feeling tired, hoarse voice and dry eyes.

Answer 3

Deafness, hoarseness?
Depression?
Any other symptoms of thyroid problems? (constipation, hair loss, cold intolerance)
Any previous thyroid problems?
FH of autoimmune disease? (thyroid, diabetes, Addison’s disease)?

Question 4

55 year old female,
Reports 6 months of feeling tired, hoarse voice and dry eyes.

went to her GP?

Answer 4

Sore throat and Hoarse
Referred to ENT (Endoscopy)
Speech & Language therapy

Dry eyes
Referred to Ophthalmologist

Admitted with ?MI nearly a year later
Chest pain and CK (2000, 10 times Normal)
TSH > 150, FT4 undetectable

Question 5

what are symptoms of hypothyroidism?

Answer 5

Question 6

what are signs of hypothyroidism?

Answer 6

Question 6

what tests would you do in response to a patient presenting with hypothyroidism?

Answer 6

Question 6

in hyperthryoidism how are FT3, TSH and FT4 levels affected?

Answer 6

Question 6

in a normal patient how are FT3, FT4 and TSH levels?

Answer 6

Question 6

in hypothyroidism how are FT3, FT4 and TSH levels affected?

Answer 6

Question 7

what are the nice guidelines on administering levothyroxine?

Answer 7

Question 8

what are key symptoms of hypothyroidism?

Answer 8

Weight Gain
Lethargy
Feeling cold
Constipation
Heavy periods
Dry Skin/Hair
Bradycardia
Slow reflexes
Goitre
Severe – puffy face, large tongue, hoarseness, coma

Question 9

what are key symptoms of hyperthyroidism?

Answer 9

Weight Loss
Anxiety/Irritability
Heat Intolerance
Bowel frequency
Light periods
Sweaty palms
Palipitations
Hyperreflexia/Tremors
Goitre
Thyroid eye symptoms/signs

Question 10

what is the prevalence of hypothyroidism?

Answer 10

Commonest endocrine condition after diabetes
1.9% in women
O.1% in men
Subclinical hypothyroidism 5%
10% of women over the age of 60

Question 11

what are congenital causes of hypothyroidism?

Answer 11

Developmental
agenesis / maldevelopment

Dyshormonogenesis
trapping / organification

Question 12

what is the incidence of primary hypothyroidism?

Answer 12

Incidence of congenital hypothyroidism 1 in 3500 births
All babies screened in the UK

Question 13

what are aquired causes of primary hypothyroidism?

Answer 13

Autoimmune thyroid disease
Hashimotos / atrophic

Iatrogenic
postoperative / post- radioactive iodine
External RT for head and neck cancers
antithyroid drugs, Amiodarone, Lithium, Interferon

Chronic iodine deficiency

Post-subacute thyroiditis
Post partum thyroiditis

Question 14

what are causes of secondary / tertiary hypothyroidism?

Answer 14

Pituitary / hypothalamic damage from…

pituitary tumour eg tumour

craniopharyngioma

post pituitary surgery or radiotherapy

Question 15

32 year old woman
Some tiredness over last 6 months, but stressful job changes
No weight change
No family history
FT4 15 pmol/l (N: 10-25)
TSH 5.5 mU/l (N: 0.3 to 4.5)

Answer 15

Question 16

43 year old woman
Hypothyroid for last 6 years
On Levothyroxine 125mcg per day
TFTs normal
Still complains of Tiredness, weight gain, dry skin and constipation.

Answer 16

Question 17

28 year old woman
Hypothyroid for 4 years
On Levothyroxine 125mcg daily
TSH between 2 – 4mU/l over last couple of years, most recent TSH 2.1mU/l
She want to get pregnant

Answer 17

1: Adequate Preconception replacement (TSH < 2.5mU/l
2: Empirical dose increase in early pregnancy (20-30% - double dose on 2 days weekly)
3: Regular monitoring (4 weekly until 20 weeks)
4: Aim for TSH in lower half of normal range
5: Post-natal: reduce levothyroxine to pre-pregnancy dose 2 weeks following delivery
6: Recheck 2 to 3 months post pregnancy

Question 18

65 year old woman
Hypothyroid for 30 years
On Levothyroxine 175mcg daily
Feels better with when her TSH is suppressed and had maintained this for the last 10 years.
Now concerned as having occasional palpitations

Answer 18

20% of treated hyperthryoidism patients have subclinical hyperthyroidism

Risks of overtreatment: AF & Osteopenia/Fracture