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Year 3 - Preparation for Clinical Practise > Diagnosing Thyroid Dysfunction in Adults in Primary Care > Flashcards

Diagnosing Thyroid Dysfunction in Adults in Primary Care Flashcards

1
Q

When do you test thyroid function

A
  • Patients with signs or symptoms suggestive of thyroid dysfunction
  • Patients with a goitre or thyroid nodule.
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2
Q

In what conditions what you recommend offering thyroid function testing to

A
  • Type 1 diabetes or other autoimmune conditions
  • atrial fibrillation
  • considered for patients with depression or unexplained anxiety
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3
Q

Who is an annual check of thyroid function recommended or

A

= patients with type 1d diabetes

  • down syndrome and turner syndrome
  • postpartum thyroiditis women
  • neck irradiations
  • untreated subclinical hypothyroidism or this ewho have stopped taking their levothyroxine treatments if they have features suggesting underlying thyroid disease
  • stopped antithyroid drugs
  • patients who have had previous surgery
  • patients on long term treatment for hypothyroidism
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4
Q

What patients receive a 6 to 12 monthly check of the thyroid

A

= patients on lithium therapy

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5
Q

What patients have a 6 monthly check of the thyroid

A
  • patients who have had previous radioiodine treatments

- patients on amiodarone therapy and for the first year following cessation of treatment

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6
Q

What are the signs and symptoms of hypothyroidism

A
  • wekaness
  • lethargy
  • depression
  • weight gain
  • cold intolerance
  • constipation
  • menstrual irregularity
  • dry or coarse skin
  • hair loss
  • myalgia
  • eyelid/facial swelling
  • deep voice
  • bradycardia
  • diastolic hypertension
  • goitre
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7
Q

What are the symptoms of hyperthyroidism

A
  • irritability and anxiety
  • heat intolerance
  • excessive sweating
  • palpitations
  • tremor
  • weight loss with increased appetite
  • increased bowel frequency
  • oligomenorrhoea
  • gynaecomastia
  • tachycardia
  • warm and moist skin
  • hair loss
  • proximal myopathy
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8
Q

What is a thyroid storm

A
  • signs of decompensated hyperthyroidism

- medical emergency and requires immediate transfer to hospital

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9
Q

what are the signs of a thyroid storm

A
  • high output cardiac failure
  • hypertension
  • fever
  • GI effects including diarrhoea, vomiting, abdominal pain and jaundice
  • neurological effects including altered consciousness and rarely seizures
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10
Q

What is toxic mulitnodular goitre

A

Toxic multinodular goitre arises where there is over-secretion of thyroid hormones from multiple autonomously functioning thyroid nodules, which are almost always benign

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11
Q

What is post viral thyroiditis

A

De Quervain’s thyroiditis (sometimes called ‘subacute thyroiditis’) causes painful swelling of the thyroid gland

It is believed to be triggered by a viral infection such as mumps or influenza

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12
Q

What is postpartum thyroiditis

A
  • painless condition occurring in the postnatal period

- characterised by a thyrotoxic phase followed by a hypothyroid phase of usually up to several months

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13
Q

Why does the production of thyroid hormones decrease in pregnancy

A

Pregnancy is a stress test for the thyroid. In normal pregnancy the thyroid gland increases in size by 10%, and the production of thyroid hormones increases by 50%. Placental human chorionic gonadotropin (hCG) has a similar structure to thyroid stimulating hormone (TSH) and cross-reacts with the receptor. This results in reduced plasma TSH levels throughout pregnancy

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14
Q

Whicih pregnant women get thyroid test

A
  • type 1 diabetes - recommended before conception and again at 3 months post party
  • previous history of thyroid disease
  • current thyroid disease
  • family history of thyroid disease
  • goitre
  • symptoms of hypothyroidism
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15
Q

What are the risk associated with hyperthyrodism in pregnancy

A
  • miscarriage
  • gestational hypertension
  • prematurity
  • low birth weight
  • intrauterine growth restrictions
  • still birth
  • thyroid storm
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16
Q

What are the risks associated with hypothyroidism in pregnancy

A
  • miscarriage
  • preterm delivery
  • LBW
  • gestation hypertension
  • impaired fatal neurocognitive development
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17
Q

Name drugs that can affect thyroid function

A

Amiodarone

Lithium

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18
Q

Describe how amiodarone affects thyroid function

A
  • Induces thyrotoxicosis

Type 1 (20% of cases) is caused by a large iodine load precipitating thyroid autonomy

Type 2 (80% of cases) is a form of destructive thyroiditis and is responsive to steroid treatment.

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19
Q

How does lithium affect thyroid function

A

Patients taking lithium can experience overt or subclinical hypothyroidism, and a mild self-limiting thyroiditis can occur in a small proportion of patients on initiation of treatment

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20
Q

when do you request TSH alone

A
  • when secondary thyroid dysfunction is not suspected
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21
Q

if TSH is above the reference range…

A

reference range then measure FT4 in the same sample

22
Q

If TSH is below the reference range ….

A

then measure FT4 and FT3 in the same sample

23
Q

when do you tend to measure TSH and FT4 together

A
  • when there is secondary thyroid dysfunction suspected
24
Q

Give some common situations when you measure TSH and FT4 together

A
  • diagnosing and monitoring thyroid disorders in pregnancy
  • optimising levothyroxine therapy in newly diagnosed patients with hypothyroidism who have persistent symptoms after starting levothyroxine
  • monitoring patients with hyperthyroidism in the early months after surgery
25
Q

Name some rarer situations where you would measure TSH and FT4 together

A
  • diagnosis and monitoring of treatment for central hypothyroidism
  • end organ thyroid hormone function resistance
  • TSH-secreting pituitary adenomas
26
Q

why do you not generally recommend routine checks of autoantibodies for thyroid in primary care

A
  • they are neither sensitive or specific for autoimmune thyroid disease
27
Q

in practise when do you test TOP autoantibodies

A
  • for patients with subclinical hypothyroidism testing TOP autoantibodies is useful in assessing the likelihood of progression to overt hypothyroidism
  • if TPO autoantibodies are positive this predicts the likelihood of the patient developing overt hypothyroidism and can guide replacement and further monitoring
28
Q

what is the difference between total levels of thyroid hormones and free measurements

A

Totals levels - are total amount of thyroid hormones whereas free are only those that are not bound to proteins
- total hormone levels are affected by alterations in binding proteins that can occur in patients taking oestrogen’s or in pregnancy

29
Q

what is the difference between overt and subclinical hypothyroidism

A

Overt primary hypothyroidism

  • low FT3
  • Low FT4
  • Raised TSH

Subclinical hypothyroidism

  • normal FT3
  • normal FT4
  • raised TSH
30
Q

what is the difference between overt and subclinical hyperthyroidism

A

Overt primary hyperthyroidism

  • raised T3
  • raised T4
  • low TSH

Subclinical hyperthyroidism

  • normal T3
  • normal T4
  • low TSH
31
Q

what are the causes of overt primary hypothyroidism

A
  • autoimmune process such as Hashimoto’s disease or atrophic thyroiditis
  • radio iodine treatment
  • thyroidectomy
32
Q

What are the causes of subclinical hypothyroidism

A
  • medical interactions
  • inadequate replacement after radioactive treatment
  • partial thyroidectomy
  • iodine deficiency
  • thyroid genesis
  • ## non thyroidal illness
33
Q

when should you consider levothyroxine

A

NICE recommend considering treatment with levothyroxine for patients who have a TSH of 10 mU/litre or higher on two separate occasions three months apart.

  • here TSH remains above the reference range but lower than 10 mU/litre, then consider a six month trial of treatment if patients are under 65 and they also have symptoms of hypothyroidism
34
Q

How often should you monitor patients with subclinical hypothyroidism

A

Where patients are untreated or have stopped their treatment, then monitor their TSH and FT4 once a year if they have features suggesting underlying thyroid disease, for example previous thyroid surgery or raised thyroid autoantibodie

  • reduce monitoring to once very two to three years if they have no underlying thyroid disease
35
Q

What causes overt primary hyperthyroidism

A
  • Graves

- toxic multinodular goitre

36
Q

What are the causes of subclinical hyperthyroidism

A
  • graves disease in young patients

- multi nodular goitre and solitary nodules are more common in older patients

37
Q

When should you refer patients with subclinical hyperthyroidism to the endocrinologist

A

Patients with confirmed persistent subclinical hyperthyroidism who have two TSH readings lower than 0.1 mU/litre at least three months apart and who also have evidence of thyroid disease (for example, a goitre or positive thyroid antibodies) or symptoms of thyrotoxicosis, require referral to an endocrinologist

38
Q

What are the long term effects of subclinical hyperthyroidism

A
  • increased risk of AF in people older than 65 with suppressed TSH
  • bone mineral density is decreased
39
Q

what are the long term effects of overt hyperthyroidism

A

increased bone turnover leading to increased risk of osteoporosis and fracture

40
Q

How should the level of TSH change during pregnancy from seven to 12 weeks and in the second and third trimester

A
  • 7-12 weeks - Reduce the lower limit of the reference range of TSH by approximately 0.4 mU/L and the upper limit by 0.5 mU/L (corresponding to a TSH reference range of approximately 0.1 mU/L to 4 mU/L)

second and third trimester
- there should be a gradual return of TSH towards the non pregnant normal range

41
Q

what can be the diagnose with a Low FT and a normal or low TSH (inappropriate)

A
  • Non-thyroidal illness
  • Central hypothyroidism (pituitary or hypothalamic disease)
  • Assay interference
42
Q

what can be the diagnosis of a high FT4 with an inappropriately normal or high TSH

A
  • drugs - amiodarone or heparin
  • non-compliance with thyroxine replacement
  • Thyroid hormone resistance
  • TSH secreting pituitary adenoma
  • assay interference
43
Q

what should you not do in central hypothyroidism

A

it is important not to prescribe levothyroxine while awaiting urgent assessment by an endocrinologist if there is any suspicion of central hypothyroidism. Giving levothyroxine to a patient with hypoadrenalism without first correcting the underlying deficiency of cortisol with glucocorticoid replacement can be life threatening

44
Q

what is assay interference

A

This can occur when the presence of heterophilic antibodies in the patient’s blood interfere with the laboratory assay’s ability to detect TSH.

45
Q

name the symptoms that need an urgent referral (two week rule)

A
  • unexplained hoarseness or voice changes associated with a goitre
  • cervical lymphadenopathy associated with a thyroid mass (usually deep cervical or supraclavicular region)
  • a rapidly enlarging painless, thyroid mass over a period of weeks
46
Q

What are symptoms that need a same day referral

A

stridor associated with a thyroid mass

47
Q

what is arranged following a referral for cancer

A
  • ultrasound imaging

- fine needle aspiration

48
Q

How can you treat hypothyroidism in primary care

A

levothyroxine

49
Q

what patients with hypothyroidism require referral to an endocrinologists

A
  • central hypothyroidism
  • persistant anomalous or discordant thyroid function tests which cannot be explained by an intercurrent illness, medication or assay interference
  • any patients with subacute thyroiditis
  • patients with pre-exisiting cardiac disease
  • patients who you suspect have an uncommon cause of hypothyroidism
  • any patient who is pregnant
  • patients with postpartum thyroiditis whose thyroid function tests show a hypothyroid pattern
  • myxoedema coma
  • suggestive symptoms and signs including confusion, hypothermia, hypotension, bradycardia and drowsiness
50
Q

all patents with ..

A

hyperthyroidism need referral to an endocrinologists

51
Q

What should you prescribe for patients with hyperthyroidism who are awaiting a specialist appointment

A
  • prescribe a beta blocker unless contraindicated if they have beat adrenergic symptoms such as tremor or tachycardia, and titrating the dose according to clinical response

Year 3 - Preparation for Clinical Practise (33 decks)

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