Hyperthyroidism

Question 1

A 26 year old female presents with tiredness, palpitations and heat intolerance. She has a diffusely enlarged thyroid. How would you assess her?

Answer 1

Impression
Given sx, this is likely a presentation of hyperthyroidism. Most likely aetiology in young female patient is Graves Disease, however would want to rule out multi nodular goitre and thyroid carcinoma given thyroid mass. Could be acute Hashimoto’s. Concerned about complication such as thyroid storm.

Goals

• undertake thorough H/E/I
• initiate appropriate management

Question 2

Hyperthyroidism - History

Answer 2

History

• Sx: heat intolerance, weight loss, hair loss, GI symptoms, etc, hyperactivity, agitation.
• HPC/PMHx: time course, other autoimmune disease (thyrogastric cluster)
• REDF: psychiatric (agitation, confusion, delirium), cardiovascular (tachycardia, arrhythmia, HTN), heat intolerance, severe N/V - Thyroid storm. Weight loss, fevers, night sweats (Malignancy)
• Obstructive sx: stridor, SOB, dysphonia, dysphagia, Pemberton’s sign
• Fam Hx, Medications (caffeine, stimulants)
• SNAP

Question 3

Hyperthyroidism - Examination

Answer 3

Examination

• General observation + vitals
• Neck/thyroid examination: character, location, size, swallow test
• Lymph nodes examination
• Cardiovascular examination: rate, rhythm, murmurs
• Systems review: weight etc

Question 4

Hyperthyroidism - Investigations

Answer 4

Investigations
- Key/diagnostic: TFTs (T3/4, then TSH), thyroid antibodies. Thyroid biopsy and histopathological analysis

• Bedside: ECG, VBG, vitals
• Bloods: FBC, Iron studies, B12/Folate, UEC, CRP/ESR, lipid panel, BSL
• Imaging: Thyroid US, Radioactive iodide uptake (hot/cold nodules)
• other: FNA of thyroid mass

Question 5

Hyperthyroidism - Management

Answer 5

Management
Acute mx of thyroid storm:
- propanolol
- propothiouracil
- potassium iodine
- dexamethasone

Otherwise, for hyperthyroidism
Supportive/symptomatic
- anti-thyroid drugs (PTU, carbimazole)
- patients shouldn't be on anti-thyroid medications long-term
- beta blocker for palpitations

Definitive

• radioiodine 131
• surgical thyroidectomy (or lobectomy) - usually requires thyroid replacement therapy

Ongoing
- regular monitoring/review