Clinical Thyroid Disease

Question 1

Give some symptoms of hypothyroidism

Answer 1

Weight gain
Lethargy
Feeling cold
Constipation
Heavy periods
Dry skin/hair
Bradycardia
Slow reflexes
Goitre
In severe cases - puffy face, large tongue, hoarseness, coma

Question 2

Giver some symptoms of hyperthyroidism

Answer 2

Weight loss
Anxiety/Irritability
Heat intolerance
Bowel frequency
Light periods
Sweaty palms
Palpitations
Hyperreflexia/tremors
Goitre
Thyroid eye symptoms

Question 3

What are classes of thyrotoxicosis causes?

Answer 3

Primary
Secondary
Thyrotoxicosis without hyperthyroidism

Question 4

What are the causes of primary thyrotoxicosis?

Answer 4

Grave’s disease (70%)
Toxic multinodular goitre (20%)
Toxic adenoma

Question 5

What are the causes of secondary thyrotoxicosis?

Answer 5

Pituitary adenoma secreting TSH

Question 6

What are the causes of thyrotoxicosis without hyperthyroidism?

Answer 6

Destructive thyroiditis

Excessive thyroxine administration

Question 7

What proportion of hyperthyroidism is caused by Grave’s disease? Is there a gender imbalance?

Answer 7

75%

5:1 female:male incidence

Question 8

What are the autoimmune key points in Grave’s disease?

Answer 8

Thyroid peroxidase antibodies

TSH receptor antibodies

Question 9

What is needed to make the diagnosis?

Answer 9

Either hyperthyroidism together with TSH receptor (thyroid) antibodies
OR
Hyperthyroidism with symptoms like goitre, exophthalmus etc

Question 10

What is the most common cause of thyrotoxicosis in the elderly? Is there Grave’s disease?

Answer 10

Multi-Nodular goitre

No

Question 11

What are some of the potential treatment modalities in hyperthyroidism?

Answer 11

Anti-thyroid drugs
Surgery
Radioactive Iodine

Question 12

What are the two main anti-thyroid drugs?

Answer 12

Carbimazole

Propylthiouracil

Question 13

What are the two available drug regimes/patterns for anti-thyroid drugs? Which is usually the preferred of the two - why?

Answer 13

Titration regime - dose started high and then reduced gradually

Block - Replace - high dose is maintained but thyroxine gradually introduced to counter

Titration regime is usually preferred thanks to fewer side effects

Question 14

What is a common side effect of anti-thyroid drugs? What is a rarer more serious side effect?

Answer 14

Rash

Agranulocytosis - patients must be warned that in the case of a very painful sore throat that the medication must be stopped

Question 15

What are the pros and cons when comparing high dose ablative radio iodine with variable calculated radioiodine?

Answer 15

High dose ablative is 90% curative but causes hypothyroidism in 70% of cases

Variable calculated has a 60-90% cure rate but less incidence of hypothyroidism

Question 16

What is subclinical hyperthyroidism?

Answer 16

The TSH is suppressed because the pituitary has detected an increase in thyroid hormone but there are normal levels of free thyroid hormone, so there may be no noticed symptoms

Question 17

Compare the expected levels of TSH and thyroid hormones in primary, secondary and subclinical/compensated hypothyroidism?

Answer 17

Primary - high TSH, low T3 and T4

Secondary - low TSH, low T3 and T4

Subclinical - high TSH, normal T3 and T4

Question 18

What is the most common endocrine disease after DM?

Answer 18

Hypothyroidism

Question 19

What are the two general classes of causes of primary hypothyroidism?

Answer 19

Congenital

Acquired

Question 20

What are the causes of acquired primary hypothyroidism?

Answer 20

Autoimmune hypothyroid
- Hashimoto’s / atrophic

Iatrogenic

• post op
• external RT
• antithyroid drugs

Chronic iodine deficiency

Question 21

What are the major causes of secondary/tertiary hypothyroidism?

Answer 21

Pituitary damage

Hypothalamic damage

Question 22

What are the two key blood tests for investigation of suspected hypothyroidism?

Answer 22

TSH plasma/ T4 plasma

Autoantibodies : Thyroid peroxidase antibodies

Question 23

What is the main treatment for hypothyroidism?

Answer 23

Levothyroxine (T4) tablets

Question 24

What are some contraindications which would prompt adaptation of normal hypothyroidism treatment regimes?

Answer 24

IHD
Pregnancy
Postpartum thyroiditis

Question 25

What indicates that treatment should be started in subclinical hypothyroidism?

Answer 25

Consider treatment when TSH > 10
OR
TSH > 5 with thyroid antibodies
OR
TSH elevated with symptoms

Question 26

What is the requirement with regard to levothyroxine (T4) treatment during pregnancy?

Answer 26

Dose increase is required

Question 27

What should be considered when examining goitres?

Answer 27

Size, shape, consistency, mobility
Bruit presence
Associated lymph nodes
Tracheal position
Clinical thyroid status

Question 28

Which autoimmune diseases may cause goitre? Are these hyperthyroid or hypothyroid conditions?

Answer 28

Grave’s disease - hyperthyroidism

Hashimoto’s -hypothyroidism

Question 29

What are some of the different types of goitre?

Answer 29

Multi-nodular
Diffuse
Cysts
Tumours

Question 30

What is the main test for a solitary thyroid nodule?

Answer 30

FNA - fine needle aspiration

Question 31

What is the most common type of thyroid cancer?

Answer 31

Differentiated papillary cancer - local lymph node spread, good prognosis

Question 32

What factors are in favour of a poorer prognosis in thyroid cancer?

Answer 32

Aged under 16 or over 45
Tumour size
Metastases and local spread
TNM stage

Question 33

What follow-up monitoring is common after thyroid cancer remission?

Answer 33

Thyroglobulin monitoring