hyperthyroidism

Question 1

management of acute phase of hyperthyroidism

Answer 1

give the patient propranolol (10-40mg)
gradually withdraw once thyroid levels return to normal

Question 2

Medical management of hyperthyroidism , Graves disease

Answer 2

give antithyroid drugs for 12-18 months;
Carbimazole or neomercazole or methiomazole with a dosage of 30-40 mg for 1 to 2 months then reduce to 15-20 mg
or give PTU for 1 to 2 months at a dose of 100-150 mg every 6 hours then reduce to 50-200mg

Question 3

what are the complications of the antithyroid drugs

Answer 3

Propylthiouracil (hepatotoxic),
carbimazole (agranulocytosis-leukopenia presents with fever and sore throat and teratogenic)

Question 4

Surgical management of graves disease

Answer 4

Antithyroid drugs must first be taken to reach euthyroid (about 6 weeks) and then a full thyroidectomy can be performed,
SSKI 2 weeks before the surgery also be taken to decrease vascularity

Question 5

what are the complications of surgical management of graves disease ?

Answer 5

hypoparathyroidism
recurrent laryngeal nerve damage (hoarseness )
external laryngeal nerve damage ( poor vocal volume)

Question 6

when can radioactive therapy in Graves disease be given

Answer 6

is usually the preferred treatment in most patients
but patient must reach euthyroid first
can be administered immediately except in:
elderly patients
patients with IHD
severe thyrotoxicosis
large glands
________________________________________
must not get pregnant 6-12 months after
may worsen eye disease and hypothyroidism happens in most cases

Question 7

Management of ophthalmology in Graves disease

Answer 7

1- Give prednisolone after RAI 100mg , in gradually diminishing doses for 6-12 weeks
2- keep head elevated at night to diminish periorbital oedema

if steroid therapy is not effective , X-ray too the retrobulbar area may be helpful
orbital decompression if vision is threatened

Question 8

management of hyperthyroidism/graves disease during pregnancy

Answer 8

1- Radioactive iodine therapy is contraindicated,
2- PTU in the first 3 months then switch to carbimazole
3- thyroidectomy can be performed in the second trimester
4- PTU has no effect on breastfeeding

Question 9

what is toxic adenoma ?

Answer 9

1- also known as plummer’s disease,
2- almost always follicular adenoma (never malignant )
3- signs of hyperthyroidism without any ophthalmic features
4- nodule on one siide

Question 10

thyroid scan findings of toxic adenoma?

Answer 10

hot nodule with suppressed uptake contralaterally

Question 11

best treatment for toxic adenoma

Answer 11

thyroidectomy

Question 12

what are the findings of toxic multinodular goitre on RAI?

Answer 12

patchy distribution may show, multiple functioning nodules appear

Question 13

what is the Jod-basedow phenomenon ?

Answer 13

also known as iodine induced hyperthyroidism, pts with multi nodular goitre can often be precipitated by jod basedow

Question 14

what is the treatment for toxic multinodular goitre ?

Answer 14

surgery; thyroidectomy

Question 15

What is Subacute thyroiditis

Answer 15

inflammatory disorder of the thyroid gland , usually after a viral infection usually resolves over weeks or months

Question 16

signs and symptoms of subacute thyroiditis

Answer 16

tender thyroid gland, no signs of ophthalmology, accompanied with signs of thyrotoxicosis ,fever malaise soreness in the neck

Question 17

what are the lab findings in Subacute thyroiditis and findings on RAI ?

Answer 17

T3 and T4 will be high whilst TSH will be low initially , as the disease progresses T4 and T3 will drop and TSH will rise
RAI uptake is initially low but as the patient recovers the uptake increases

Question 18

what is the management of subacute thyroiditis ?

Answer 18

1- symptomatic treatment , give paracetamol 0.5g four times a day
2- L-thyroxine is indicated in the hypothyroid phase of the disease and may need to continue on L thyroxine long term

Question 19

when does a thyroid storm (thyrotoxic crisis) happen?

Answer 19

usually if the patient stops taking anti thyroid medications in Graves disease, due to infection or due to surgical stress

Question 20

what are the clinical clues to thyrotoxic crisis (thyroid storm ) ?

Answer 20

fever, coma , anorexia , tacchycardia which may evolve to tachyarrythmias, pulmonary oedema, shock, confusion

Question 21

what are the general measures for the management of thyrotoxic crisis ?

Answer 21

after Measuring T3 and T4 levels along with TSH general measures :
fluids used as indicated
a cooling blanket for the pyrexia
propranolol may be given to decrease conversion of T4 to T3

Question 22

what are the specific measures for the management of thyrotoxic crisis ?

Answer 22

PTU is the anti thyroid drug of choice and is used in high doses as 1000 mg of PTU p.o or given nasogastrically,
followed by by PTU 250 mg of it every 6 hours
then an hour later give Lugol’s solution or SSKI to inhibit the release of thyroid hormone
finally dexamethasone should be given to lower body temperature

Question 23

Graves disease syndrome

Answer 23

pretibial myxedema , exopthalmous, ptosis, thyrtoxicosis and goitre

Question 24

what are the RAI findings in Graves disease

Answer 24

diffuse increased uptake

Question 25

RAI findings in subacute thyroiditis ?

Answer 25

decreased uptake

Question 26

when not to use RAI

Answer 26

in pregnant women , with large goitres and with compressive symptoms and elderly patients

Question 27

management in toxic multi nodular goitre ?

Answer 27

start on propanolol and then reach euthyroid stage and then perform a thyroidectomy

Question 28

what is the rhythmn in which TSH is released in ?

Answer 28

released in a pulsatile diurinal rhythm ( highest at night)

Question 29

which hormones would change first in any thyroid affection ?

Answer 29

TSH first before T3 and T4

Question 30

what medication is known to cause hyperthyroidism?

Answer 30

amiodarone

Question 31

what is the NO SPECS classification of Graves’s ?

Answer 31

class 0 : no signs or symptoms
class 1 : only ocular signs
class 2 : soft tissue involvement
class 3 : proptosis
class 4 : extraocular muscle involvement
class 5 : corneal involvement
class 6 : sight loss

Question 32

how is a diagnosis of graves disease made ?

Answer 32

1- if eye disease is present , graves can be diagnosed with no further tests
2- no eye disease ? hyperthyroid patient with or without goitre should do a radioiodine uptake test

Question 33

what are the results seen with radioiodine uptake test in graves disease ?

Answer 33

increased diffuse uptake

Question 34

what specific lab test can be used for graves disease?

Answer 34

TSH receptor antibody

Question 35

what if steroid therapy is not effective in managing eye disease in Graves ?

Answer 35

external X ray therapy too the retrobulbar area
if vision is threatened orbital decompression can be used

Question 36

what are the TFT results in hyper, hypo thyroidism , in hypopituitarism and in TSH secreting tumors

Answer 36

hyperthyroidism - TSH low , T3,T4 is high
hypothyroidism - TSH high, T3,T4 is low
hypopituitarism - TSH low, T3,T4 low
TSH secreting tumor - TSH high, T3,T4 high

Question 37

what is the presentation of TSH secreting tumors ?

Answer 37

• FT4 & FT3 is elevated but TSH is normal or elevated
• Visual field examination may reveal temporal defects
  MRI usually shows a pituitary tumor

Question 38

what are the contraindications to using beta blockers (propranolol) ?

Answer 38

asthma
COPD