Hyperthyroidism Flashcards
What are the symptoms of hyperthyroidism?
Anxiety
Insomnia
Brain fog
Heat intolerance
Clammy/sweaty
Increased appetite
Weight loss
Tremor
Palpitations
Eye signs In Hyperthyroidism?
Lid lag, Lid retraction
Eye signs in graves?
Proptosis
Chemosis
Ophthalmoplegia
Examination of someone with thyroid disease?
Nails - Thyroid acropachy
Sweaty/clammy
Hands out for tremor - VERY KEY SIGN
Palmar erythema
AF
Proximal myopathy
Eye disease
Goitre
Pre tibial myxoedema
Causes of hypothyroidism
Hashimotos - progressive autoimmune destruction of thyroid
DeQuervains - tender thyroid - Initially thyrotoxicosis, then hypothyroid, then euthyroid
Iatrogenic thyroid - amiodarone, radioactive iodine/surgery
Age related hypothyroidism
Iodine deficiency
Pendreds (deafness) syndrome
Pituitary failure
Amiodarone thyroidiitis
Post partum thyroiditis
Blood tests associated with hashimotos
Anti-TPO (thyroperoxidase)
Anti-thyroglobulin abs
Name some conditions linked to hashimotos?
Vitiligo
Addisons
Alopecia
Pernicious anaemia (intrinsic factor/parietal cell abs)
Essentially autoimmune disorders
What is the difference between hashimotos and dequervains
Dequervains is not progressive
Tender thyroid which has 3 stages of hyperthyroidism/Hypo/Euthyroid
Often the result of a viral infection
Hashimotos is the result of lymphocytic destruction of the thyroid follicles
What are the signs of Graves ophthalmopathy
Graves’ ophthalmopathy: Reddened eyes, excessive lacrimation, periorbital oedema, proptosis, conjunctival oedema and ophthalmoplegia
Exophtalmos
Lid retraction - sclera visible above the cornea
How do you examine the neck when doing thyroid exam?
Inspect
Palpate
- Lymph nodes
- goitre - is it tender
patient is given water and asked to swallow
Swallow water as palpating goitre
ask to stick tongue out
Look for scars associated with thyroidectomy
Percuss for retrosternal extension
Auscultate for bruit
What happens to reflexes in thyroid disease
Hyperthyroid - Brisk
Hypothyroid - Slow relaxing
Causes of hyperthyroidism?
Graves disease
First stage of DeQuervains
Toxic multinodular goitre
Malignancy
Recent child birth - post partum thyroiditis
Drug induced - iodine/contrast/amiodarone
Treatment of hyperthyroidism
Carbimazole/Propylthiouracil
- Block and replace.
- Carbimazole started at a dose of 30mg and tapered down.
- Levothyroxine is normally started when T4 is in the normal range
Risk of rash and agranulocytosis
Radioiodine
- This can worsen eye disease
Surgery
- Risk of hoarse voice - recurrent laryngeal nerve
Symptoms - propranolol
Treatment of Graves ophthalmopathy
Stop smoking
Lubricating eye drops
Consider steroids - Soft tissues signs, pain behind eyes and changing appearance
Surgical opinion - diplopia or proptosis, keratosis or change in visual acuity
What happens with radioiodine in patients with graves eye disease
May make eye disease worse
Therefore it is contraindicated in those with severe ophthalmopathy
What are important questions when assessing for toxic multinodular goitre?
Dysphagia or stridor - may need urgent surgery
Hoarse voice - compression/malignany infiltration of RLN
Pain with rapid enlargement suggests bleeding into nodule
Investigations in hyperthyroidism?
Bloods - TSH/T4
Consider autoimmune panel - addisons etc
Anti-TSH receptor ab
Thyroid uptake scan - Increased uptake in graves
Investigations in TMNG
TFTs - subclinical hyperthyroidism (low TSH, normal T3/4 is common)
Thyroid auto-antibodies should be negative
Thyroid ultrasound for detecting impalpable nodules
CT thorax to assess goitre for compression
Thyroid uptake scans
Fine needle aspiration
Thyroid uptake scans - interpret
Increased uptake;
Graves - diffuse uptake
TMNG - focal uptake
Toxic adenoma - focal uptake
Decreased uptake
Thyroiditis
Iodine/amiodarone induced
Treatment of toxic multinodule goitre
Radioactive iodine - may be a transient increase in size
Surgery
Anti-thyroid drugs dont normally work
What are symptoms of hypothyroidism
Dry skin and hair loss
Cold intolerant
Constipation
Peripheral oedema
Carpal tunnel syndrome
Neck swelling - if present ask about compressive symptoms
Menstrual disturbances.- menorrhagia
Obstructive sleep apnoea - ask about snoring
What is an important consideration if you suspect co-existing addisons and hypothyroidism?
If you only give Thyroid replacement, this can precipitate an adrenal crisis.
Need to ask about addisons symptoms such as abdominal pain/postural symptoms
Tell me about hypothyroidism in pregnancy
Hypothyroidism in the early stages of pregnancy is known to have a detrimental effect on foetal neurodevelopment.
Thyroid requrieemnts increase during pregnancy and therefore baseline requirements must increase by 25-50%
Why do we have to be careful starting levothyroxine in the elderly?
They may have coexisting IHD and therefore its important to start low doses of thyroxine as it could precipitate an acute event
Counsel me on carbimazole
Carbimazole (on propyluracil in preg) is used to bring down thyroid levels
It can take 18 months to work and has 50% success rate - we can do it again if it doesnt work
Start at a dose of 30mg and taper down until thyroid hormone is in range
SEs; Agranulocytosis/rash
Counsel me on Radioactive iodine
Most common treatment in america
90% successful. Takes 6 months to work
Can worsen thyroid eye disease and so is contraindicated if this exists
Cant get pregnant for 6 months
Avoid pets and pregnant women
Initially alot of radioactive iodine comes out through sweat/wee
Roughly have to stay away from them for at least 2 weeks
https://www.esht.nhs.uk/wp-content/uploads/2022/10/0706.pdf
Counsel me on surgical options - Thyroidectomy
Likely will end up hypothyroid
Will likely end of removing parathyroid glands affecting calcium
Tablets for life
Risk of damaging nerve causing hoarse voice
How do you manage thyroid eye disease?
Depends on the symptoms
STOP SMOKING
Eye drops
If mild - treat the hyperthyroidism
If symptoms of keratitis/change in visual acuity - will need seen urgently by ophthalmology
May need to consider steroids/surgical procedure
What is NOSPECS in TED
No signs or symptoms
Only lid lag/retraction
Soft tissue involvement
Proptosis
Extraocular muscle involvement
Chemosis
Sight loss due to optic nerve compression/atrophy
What are some concerning signs/symptoms on thyroid eye disease?
Optic neuropathy - visual acuity and colour vision
Exposure keratopathy - unable to blink
Double vision
If clinical disease activity score is raised may need steroids
Can do orbital decompression/surgery once disease is inactive and burnt out
What TFT results would you expect in secondary hypothyroidism?
Low TSH, Low T4
Causes; Pituitary tumour, pit surgery
What are some complications of hypothyroidism?
Carpal tunnel syndrome
Heart failure
Goitre
IHD
Be careful when starting levothyroxine in IHD and potential addisions
What are considerations in hypothyroidism and pregnancy
It can slow foetal development
Increased risk of placental abruption/pre-eclampsia
Doses of levothyroxine will need to increase 25-50% in pregnancy
Blood tests in hypothyroidism?
FBC/RP/LFT/CRP
Lipids
TFTs
HbA1c
Macrocytic anaemia - pernicious
Short synacthen - addisons
