Endo

Question 1

Important questions for thyroid eye disease

Answer 1

Whats bothering them most eg vision / discomfort

Swelling / redness / puffy
-Previous hayfever

Issues with eye movements

**Any visual loss **/ ability to focus / double vision

Unable to close eyelids

Question 2

Thyroid history - what would warrant same day / very urgent opthal review

Answer 2

Visual loss / symptoms

Question 3

Neck lump history key points

Answer 3

Is this new
- goitre often very long standing
- New is more concerning

issues with swallowing or speaking

Pain

Thyroid status

Question 4

Questions for thyroid status?

Other key parts of history?

Answer 4

Head to toe

Anxiety and mood
Energy levels
Weight

Eye symptoms

neck lump / pain

Palpitations

Bowel habit changes

Periods

tremors

Social
- SMOKING - big risk for eye disease. Must council on this
- Pregnancy especially post partum
- Seaweed - lots of iodine

Medical
-Amiodarone (often long time lag)
-Lithium
-Biologics (sometimes years leater)

Surgical history

Question 5

How thyroitoxic do you need to be to have thyroid eye disease

Answer 5

You can have it and be euthyroid / without thyrotoxicosis

Question 6

Thyroid exam

Answer 6

Eyes
- look from side
- Any redness / Swelling
- Lid retraction
- Eye movements

Vision
Snellen chart

Fundoscopy

Neck
- Throidectomy scar
- feel for lump
- feel when swallows / sticks tongue out
-Any tenderness
- Auscultate for bruis

Hands
- warm
- sweat
- tremor
- Pulse / Atrial fibrillation

Shins
- Pre tibial myoxdema (often like orange peel)
- Deep tendon reflexes

Question 7

Throid exam and this

Answer 7

Conjunctival injection

Question 8

When doing snellen chart what should you ask to speed things up

Answer 8

Whats the lowest line you can read

Question 9

Someone with thyroidectomy scar but signs of thyrotoxicosis

Answer 9

May have been partial thyroidectomy

Multinodular goitre may grow back again if some tissue left

Question 10

Why thyrotoxicosis get bruis in neck

Answer 10

Increased blood flow from metabolically active thyroid

Question 11

Answer 11

pre tibial myxodema

Question 12

Post partum thyroiditis painful?

Answer 12

Can be often not.

Thyroiditis not always painful - DONT get side tracked by absence of pain

Question 13

Differentials of thyroid neck lump

Answer 13

Short time period
- Need to rule out Cancer

Longer
- Cyst
- Nodule / multi nodular goitre
- Adenoma sometimes

Question 14

Investigations in neck lump / thyrotoxicosis

Answer 14

Bloods
- TFTs - TSH / T3/T4
- TSH receptor antibody (graves)

Ophthalmology review if any concern

Question 15

Who has raised TSH receptor antibody

Answer 15

• Graves
• Thyroid eye disease
• Sometimes amiodarone (induces the antibodies)

[Usually negative in multi nodular goitre]

Question 16

Why can you get thyroid eye disease without thyrotoxicosis

Answer 16

Eye disease is caused by the TSH receptor antibodies

Question 17

Do you treat sub clinical thyrotoxicosis

Answer 17

Yes
- They have high risk of developing osteoporosis / AF if not

Question 18

Most important red flags thyroid what would you do?

Answer 18

Visal loss including acuity

compelx opthalmoplegia

High dose steroids

Question 19

Mild thyroid eye disease treatment

Answer 19

Over the counter Selenium
Lubricating eye drops

Question 20

Thyroid eye disease steroids not working - whats next

Answer 20

Immunomodulators
Eg rituximab

Radiotherapy of orbits

Orbital decompression - last line

Question 21

Hypothyroid patients often have what else on thier bloods? what do you do?

Answer 21

Raised cholesterol

Often improves with throxine replacement

Question 22

When and how should you take thyroxine

Answer 22

on an empty stomach

Calcium eg milk reduces absorption significantly

Question 23

Treatment for graves?
When for each?

Answer 23

Symptoms
- Propranolol 40mg TDS

Carbimazole

Propylthiouracil
- Used for women who are pregnant or breast feeding

Question 24

Why propranolol specifically in thyrotoxicosis

Answer 24

Reduces conversion to t4 in peripheries

Question 25

2 Main options style of thyrotoxicosis management

Answer 25

Titration

Block and replace
- Eg high dose carbimazole with thyroxine replacement
(Use if significant thyroid eye disease and want very close control)

Question 26

Key thing to council patients when treating with antithyroid meds

Answer 26

Agranulocytosis

“If you get a severe sore throat you must stop taking this medication and present to hospital”

Question 27

When would you use radio iodine or surgery in graves

Answer 27

Toxic multinodular goitre
- Good 1st line treatment

Graves
-Usually get a 12-18 month course of carbimazole then stop
-In 2/3 will get relapse and then its worth thinking of more definitive treatment

Question 28

Key issues with radio iodine

Answer 28

2 weeks isolation at home

Especially avoid young children

Not if planning pregnancy

May end up with underactive thyroid.

Question 29

Who must NOT get radioactive iodine

Answer 29

people with ongoing thyroid eye disease -> Makes it worse

Pregnant / planning