Hyperthyroidism

Question 1

Thyrotoxicosis is the syndrome caused by excess of […] hormones in the body.
However, this isn’t usually caused by […] of the thyroid gland, rather the […] release of large amounts of stored hormones.

Answer 1

Thyrotoxicosis is the syndrome caused by excess of thyroid hormones in the body. However, this isn’t usually caused by overactivity of the thyroid gland, rather the sudden release of large amounts of stored hormones.

Question 2

Peripheral features

Fine […]
Finger clubbing
Sweating
Pretibial […]

Answer 2

Peripheral features

Fine tremor
Finger clubbing
Sweating
Pretibial myxoedema

Question 3

Head and Neck Features

[…] (depending on cause)
Thyroid […]

Answer 3

Head and Neck Features

Goitre (depending on cause)
Thyroid bruit

Question 4

Eye Features

Lid […]
Lid […]
[…] (Graves’ disease)
Periorbital […] (Graves’ disease)
[…] (Graves’ disease)

Answer 4

Eye Features

Lid retraction
Lid lag
Exophthalmos (Graves’ disease)
Periorbital oedema (Graves’ disease)
Ophthalmoplegia (Graves’ disease)

Question 5

Cardiac Features

[…] […]
[…] […] heat failure (if severe and prolonged

Answer 5

Cardiac Features

Atrial fibrillation
High output heat failure (if severe and prolonged

Question 6

Gastrointestinal Features

Answer 6

Diarrhoea

Question 7

Neurological Features

Answer 7

Muscle wasting
Proximal weakness

Question 8

Primary Causes of Hyperthyroidism (i.e. caused by thyroid dysfunction)

[…] disease
[…] thyroid adenoma
[…] goitre
Silent thyroiditis
De […] thyroiditis ([…] goitre)
[…]

Answer 8

Primary Causes of Hyperthyroidism (i.e. caused by thyroid dysfunction)

Graves disease
Toxic thyroid adenoma
Multinodular goitre
Silent thyroiditis
De Quervain’s thyroiditis (painful goitre)
Radiation

Question 9

Secondary Causes of Hyperthyroidism (i.e. not caused by thyroid dysfunction)

• Iatrogenic - […], […]
• […] producing pituitary […]
• […]
• Gestational […]
• Pituitary resistance to thyroxine (i.e. failure of negative feedback)
• […] […] (ectopic thyroid tissue in ovarian tumours)

Answer 9

Secondary Causes of Hyperthyroidism (i.e. not caused by thyroid dysfunction)

Amiodarone
Lithium
TSH producing pituitary adenoma
Choriocarcinoma (beta-hCG can activate TSH receptors)
Gestational hyperthyroidism
Pituitary resistance to thyroxine (i.e. failure of negative feedback)
Struma ovarii (ectopic thyroid tissue in ovarian tumours)

Question 10

Why would a choriocarcinoma cause hyperthyroidism

Answer 10

b-hCG can activate TSH receptors

Question 11

What is struma ovarii

Answer 11

Ectopic thyroid tissue in ovarian tumours

Question 12

Mx

Symptomatic relief
- […]

Medical Management
Either ‘titration-block’ or ‘block and replace’ regimens
- Thionamides - […], […]

Answer 12

Mx

Symptomatic relief
Propranolol
Medical Management
Either ‘titration-block’ or ‘block and replace’ regimens
Carbimazole
Propylthiouracil

Question 13

Which thionamide to use in pregnancy

Answer 13

Propylthiouracil, carbimazole is contraindicated

Question 14

Radio-iodine indications and contra-indications

Definitive management for […] goitre and […]
Contraindicated in […] disease because it may worsen symptoms, unless relapse following ATD therapy or are resistant to primary ATD treatment

Answer 14

Radio-iodine indications and contra-indications

Definitive management for multinodular goitre and adenomas
Contraindicated in Graves disease because it may worsen symptoms

Question 15

Thyroidectomy indications and complications

Indicated for […], goitres that […] other structures, potential […].
May lead to […], […], laryngeal nerve damage ([…] voice) and bleeding.

Answer 15

Thyroidectomy indications and complications

Indicated for recurrence, goitres that obstruct other structures, potential cancer.
May lead to hypoparathyroidism, hypocalcaemia, laryngeal nerve damage and bleeding.

Question 16

Thyroidectomy indications and complications

Indicated for […], goitres that […] other structures, potential […].
May lead to […], […], laryngeal nerve damage ([…] voice) and bleeding.

Answer 16

Thyroidectomy indications and complications

Indicated for recurrence, goitres that obstruct other structures, potential cancer.
May lead to hypoparathyroidism, hypocalcaemia, laryngeal nerve damage and bleeding.

Question 17

Thyroid Storm Management

IV […]
IV […]
[…] through NG tube followed by Lugol’s […] 6 hours later
[…]/hydrocortisone

Answer 17

Thyroid Storm Management

IV propranolol
IV digoxin
Propylthiouracil through NG tube followed by Lugol’s iodine 6 hours later
Prednisolone/hydrocortisone

Question 18

Complications of Hyperthyroidism

[…] storm
This may present as high […], […], confusion, nausea and severe vomiting
[…] […]
[…] […] heart failure
Osteopenia/[…]
Upper airway obstruction due to a large […]
Corneal ulcers/visual loss in Graves’ eye disease

Answer 18

Complications of Hyperthyroidism

Thyroid storm (often precipitated by surgery, trauma or infection)
This may present as high fever, tachycardia, confusion, nausea and severe vomiting
Atrial fibrillation
High output heart failure
Osteopenia/osteoporosis
Upper airway obstruction due to a large goitre
Corneal ulcers/visual loss in Graves’ eye disease

Question 19

What may precipitate a thyroid storm

Answer 19

Surgery, trauma or infection

Question 20

Important part of hx in thyroid disease

Answer 20

Both hypo- and hyperthyroidism can cause mood changes, depression and anxiety as well as menstrual disturbance.

Question 21

Specific features to Grave’s disease
1. […]/[…] - bulging of the eyes
2. lid […] - when the patient starts looking down the upper eyelid stays higher than it would normally
3. thyroid […] - soft tissue swelling in the extremities, nail clubbing, new bone growth in periosteum
4. pretibial […] - deposition of […] in the dermis (most commonly in the shins) leading to oedema and skin thickening.

Answer 21

exophthalmos/proptosis - bulging of the eyes
lid lag - when the patient starts looking down the upper eyelid stays higher than it would normally
thyroid acropachy - soft tissue swelling in the extremities, nail clubbing, new bone growth in periosteum
pretibial myxoedema - deposition of mucopolysaccharides in the dermis (most commonly in the shins) leading to oedema and skin thickening.