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A PACES > Endo > Flashcards

Endo Flashcards

1
Q

Important questions for thyroid eye disease

A

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

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2
Q

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

A

Visual loss / symptoms

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3
Q

Neck lump history key points

A

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

issues with swallowing or speaking

Pain

Thyroid status

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4
Q

Questions for thyroid status?

Other key parts of history?

A

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

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5
Q

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

A

You can have it and be euthyroid / without thyrotoxicosis

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6
Q

Thyroid exam

A

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

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7
Q

Throid exam and this

A

Conjunctival injection

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8
Q

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

A

Whats the lowest line you can read

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9
Q

Someone with thyroidectomy scar but signs of thyrotoxicosis

A

May have been partial thyroidectomy

Multinodular goitre may grow back again if some tissue left

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10
Q

Why thyrotoxicosis get bruis in neck

A

Increased blood flow from metabolically active thyroid

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11
Q
A

pre tibial myxodema

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12
Q

Post partum thyroiditis painful?

A

Can be often not.

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

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13
Q

Differentials of thyroid neck lump

A

Short time period
- Need to rule out Cancer

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

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14
Q

Investigations in neck lump / thyrotoxicosis

A

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

Ophthalmology review if any concern

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15
Q

Who has raised TSH receptor antibody

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

[Usually negative in multi nodular goitre]

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16
Q

Why can you get thyroid eye disease without thyrotoxicosis

A

Eye disease is caused by the TSH receptor antibodies

17
Q

Do you treat sub clinical thyrotoxicosis

A

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

18
Q

Most important red flags thyroid what would you do?

A

Visal loss including acuity

compelx opthalmoplegia

High dose steroids

19
Q

Mild thyroid eye disease treatment

A

Over the counter Selenium
Lubricating eye drops

20
Q

Thyroid eye disease steroids not working - whats next

A

Immunomodulators
Eg rituximab

Radiotherapy of orbits

Orbital decompression - last line

21
Q

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

A

Raised cholesterol

Often improves with throxine replacement

22
Q

When and how should you take thyroxine

A

on an empty stomach

Calcium eg milk reduces absorption significantly

23
Q

Treatment for graves?
When for each?

A

Symptoms
- Propranolol 40mg TDS

Carbimazole

Propylthiouracil
- Used for women who are pregnant or breast feeding

24
Q

Why propranolol specifically in thyrotoxicosis

A

Reduces conversion to t4 in peripheries

25
Q

2 Main options style of thyrotoxicosis management

A

Titration

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

26
Q

Key thing to council patients when treating with antithyroid meds

A

Agranulocytosis

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

27
Q

When would you use radio iodine or surgery in graves

A

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

28
Q

Key issues with radio iodine

A

2 weeks isolation at home

Especially avoid young children

Not if planning pregnancy

May end up with underactive thyroid.

29
Q

Who must NOT get radioactive iodine

A

people with ongoing thyroid eye disease -> Makes it worse

Pregnant / planning

30
Q

Acromegaly focused history

A

Brian
- Headaches
- Visual field loss
- Deafness

Snoring / OSA

Cardio
- Hypertension
- Diabetes - polyuria / dypsia
- Worse control

Sweating

Pituitary symptoms
- Libido
- Menstrual history
- Tired
- Dizzy

Bone changes
- Shape of face / jaw
- Hands and feet eg rings not fitting
- Carpal tunnel
- Dentition - Widening teeth gaps

Calcium
- Polyuria
- Bone pain

Family history
- Acromegally
- Endocrine - MEN1 / carney complex

Social history
- How affects function
- Smoking / alcohol CV health

31
Q

Acromegaly exam

A

Hands
- Size, sweat, coarse skin
- Pulse
- Pain on joints

Carpal tunnel exam

BP

Acanthosis nigrans in neck
Goitre

Inspect face and teeth

Visual field testing
Fundoscopy

  • I would like to complete a full cardiovascular assessment
  • Capillary blood glucose
  • BP
  • ECG (LVH)
  • Epsworth sleep score
32
Q

How to present acromegaly

A

I think this patient has Acromegaly as evidenced by

Any markers of disease activity

Any markers of complications
- Eg diabetes, cardiac disease

33
Q

Acromegaly investigations

A

Bloods
IGF - 1

Pituitary profile
- 9am cortisol
- T4 and TSH
- Prolactin
- Testosterone LSH / FH

Renal function

Renal profile - Especially for hypoNa
Calcium - Parathyroid adenomas in MEN1

HBA1C
Oral glucose tolerance test

Lipid profile

Imaging
ECG
Once biochemical evidence OR visual fields - MRI pituitary

Echo - likely for pre op

If OSA
-> Sleep studies

If carpal tunnel
- > nerve studies

34
Q

Why dont you measure GH in acromegaly

A

Anterior pit produces growth hormone in pulses
-> stimulates liver to produce Igf-1 continuously

ie GH levels vary through day

35
Q

Acromegaly treatment

A

Education

Optomise CV health

Diabetes management

Surgery
- May have some medical management pre op

36
Q

Acromegaly medical management

A

Dopamine agonists
- Bromocriptine / carbegoline

Somatostatin analouges
- All injectable
- Ocretide

37
Q

Complications of pit surgery

A

Acute
- Meningitis
- Haemorrhage
- Tumours close to optic chiasm - optic ischemia (often if been stretched by tumour and then sags down post op.)
- Transient diabetes insipidus / hypopituitary

38
Q

Pit hormone replacement in post op transient hypopit post op

A

Desmopressin
Levothyroxine
Hydrocortisone

39
Q
A

A PACES (9 decks)

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