Hyperthyroidism - Clinical Case Flashcards
A 30 year old woman attends clinic and presents you with a letter from a private health clinic. She has been experiencing palpitations. The letter contains the following results:
fT4 30 pmol/L (9 - 23)
fT3 11 pmol/L (3.1 – 6.8)
TSH < 0.01 mU/L (0.3 – 4.2)
What is the diagnosis? What are the possible causes of this?
Primary hyperthyroidism (high fT3, high fT4, low TSH)
Possible causes:
* Grave’s disease (autoimmune)
* Plummer’s disease
* Postpartum thyroiditis
* Viral thyroiditis (De Quervain’s)
A 30 year old woman attends clinic and presents you with a letter from a private health clinic. She has been experiencing palpitations. The letter contains the following results:
fT4 30 pmol/L (9 - 23)
fT3 11 pmol/L (3.1 – 6.8)
TSH < 0.01 mU/L (0.3 – 4.2)
What clues from the history and examination could help you work out which cause is most likely?
Grave’s Disease:
* Family history of autoimmune disease
* Weight loss
* Sweating
* Hand swelling
* Exophthalmos
* Pretibial myxoedema
Plummer’s Disease:
* Family history
* Irregularities upon examination (nodular goitre)
* Lid lag
Viral:
* Family history
* (Signs of infection) Fever
* Pain
* How long (More than 2/3 months would resolve)
Postpartum:
* History of giving birth / Recent pregnancy
A 30 year old woman attends clinic and presents you with a letter from a private health clinic. She has been experiencing palpitations. The letter contains the following results:
fT4 30 pmol/L (9 - 23)
fT3 11 pmol/L (3.1 – 6.8)
TSH < 0.01 mU/L (0.3 – 4.2)
The patient gives you a more detailed history. She has recently noticed herself to be more ‘snappy’ at work, leading to a few workplace arguments. She hadn’t been feeling herself for a while and was upset about this and had a private health screening through work. On direct questioning, she admitted to an 18 month history of palpitations, weight loss and sweating. Two aunts had neck operations and she had noticed a swelling in her own neck over the past year.
On examination she had a fine tremor and looked thin. Her pulse was 112 beats per minute and her blood pressure 106 / 70 mmHg. Examining her neck, there was a mass in the centre of her neck, which was soft, extended symmetrically either side of the midline and was not tender to touch. This mass moved with swallowing. She had bilateral exophthalmos (prominent eyes).
Now you know more, what is the likely diagnosis based on the history and examination? Explain why.
Grave’s Disease:
* Exophthalmos
* Smooth and symmetrical thyroid
* Family history AUTOIMMUNE
* 18 month history
* Not tender to touch
A 30 year old woman attends clinic and presents you with a letter from a private health clinic. She has been experiencing palpitations. The letter contains the following results:
fT4 30 pmol/L (9 - 23)
fT3 11 pmol/L (3.1 – 6.8)
TSH < 0.01 mU/L (0.3 – 4.2)
The patient gives you a more detailed history. She has recently noticed herself to be more ‘snappy’ at work, leading to a few workplace arguments. She hadn’t been feeling herself for a while and was upset about this and had a private health screening through work. On direct questioning, she admitted to an 18 month history of palpitations, weight loss and sweating. Two aunts had neck operations and she had noticed a swelling in her own neck over the past year.
On examination she had a fine tremor and looked thin. Her pulse was 112 beats per minute and her blood pressure 106 / 70 mmHg. Examining her neck, there was a mass in the centre of her neck, which was soft, extended symmetrically either side of the midline and was not tender to touch. This mass moved with swallowing. She had bilateral exophthalmos (prominent eyes).
What investigation will confirm the cause of her hyperthyroidism?
- Anti-TSH receptor antibody blood test
- Radioactive iodine uptake test (Iodine-131 / Tc99) -> thyroid scan
A 30 year old woman attends clinic and presents you with a letter from a private health clinic. She has been experiencing palpitations. The letter contains the following results:
fT4 30 pmol/L (9 - 23)
fT3 11 pmol/L (3.1 – 6.8)
TSH < 0.01 mU/L (0.3 – 4.2)
The patient gives you a more detailed history. She has recently noticed herself to be more ‘snappy’ at work, leading to a few workplace arguments. She hadn’t been feeling herself for a while and was upset about this and had a private health screening through work. On direct questioning, she admitted to an 18 month history of palpitations, weight loss and sweating. Two aunts had neck operations and she had noticed a swelling in her own neck over the past year.
On examination she had a fine tremor and looked thin. Her pulse was 112 beats per minute and her blood pressure 106 / 70 mmHg. Examining her neck, there was a mass in the centre of her neck, which was soft, extended symmetrically either side of the midline and was not tender to touch. This mass moved with swallowing. She had bilateral exophthalmos (prominent eyes).
What treatment should she receive in the short term? What are the long term treatment options?
Short term:
* Beta blockers (e.g. propanol-non specific)
* Thionamides (e.g. carbimazole or propylthiouracil) (antithiroid)
Long term:
* Continue anti-thyroid drugs
* Radiodine (Iodine-131)
* Surgery (Thyroidectomy)
