T1 L8 :Thyroid Disease

Question 1

what are the thyroid function diagnosis for patients with a goitre?

Answer 1

Hyperthyroid
Euthyroid (normal thyroid function)
Hypothyroid

Question 2

what is thyrotoxicosis

Answer 2

Overproduction of the thyroid hormone

Question 3

what do thyroid function tests test for

Answer 3

TSH 
FT3 
FT4 
thyroid autoantibodies-Anti-TPO AB - Thyroid peroxidase auto-antibody
TRAB - TSH receptor autoantibody

Question 4

what is a bruit

Answer 4

A thyroid bruit is seen in Grave’s disease from a proliferation of the blood supply when the thyroid enlarges- rush of blood causing a noise heard with a stethoscope

Question 5

a bruit can help to distinguish a goitre from a

Answer 5

Toxic adenoma

Question 6

TSH is the best biomarker for thyroid status but how long do the levels take to change in reflection to treatment?

Answer 6

6 weeks

Question 7

If there is an abundance of autoantibodies

Answer 7

Auto-immune disease

Question 8

What is a symptom of hypothyroidism

Answer 8

Facial puffiness
Dry skin
Hair loss

Question 9

what are the extreme signs for hypothyroidism

Answer 9

Diffuse hair loss
Bradycardia
Effusions, eg ascites, pericardial

Question 10

what are the causes of Causes of Primary Hypothyroidism Give 3

Answer 10

Autoimmune hypothyroidism

Hypothyroidism after treatment
     for hyperthyroidism (iatrogenic)

Thyroiditis

Drugs (e.g. lithium, amiodarone)

Congenital hypothyroidism

Iodine deficiency (not UK)

Question 11

what are the levels of biomarkers for primary hypothyroidism

Answer 11

Increased TSH

Low T4 and T5

Question 12

what are the causes of secondary hypothyroidism

Answer 12

diseases of the
hypothalamus
or pituitary

Question 13

what are the levels of biomarkers in secondary thyroid diseases

Answer 13

A low TSH

Low T4 and low T3

Question 14

when looking at results how do you interpret them

Answer 14

Look at FT4 levels- determines hypo/hyper

look at TSH- determines primary or secondary

Question 15

what is the treatment for hypothryoidism

Answer 15

Start with thyroxine (T4) 100 g daily

Aim normal FT4 without TSH suppression

Question 16

what is the dose if patients are elderly

Answer 16

Unless elderly/ischaemic heart disease

Start 25 g daily with increments 4-6 weekly

Question 17

what does Myxoedema mean

Answer 17

a coma -accumulation of glycosaminoglycans in interstitial spaces of tissues

Question 18

what is graves disease

Answer 18

Chronic autoimmune-antibody working on TSH receptors hyperthyr…

Question 19

what is Chronic autoimmune thyroiditis

Answer 19

Hashimoto’s disease
With a goitre
With a lymphocytic infiltration

Question 20

what is thyroiditis

Answer 20

Blip of high T4 then extremely low - longer hypothyroidism associated with pregnancy or 1 year post
partum

The goitre is tender

Question 21

why can pregnancy cause hyperthyroidism

Gestational thyrotoxicosis

Answer 21

HCG in abundance similar in structure to TSH and stimulates receptors but only for 1st trimester

Question 22

what are the symptoms of hyperthyroidism

Answer 22

Weight loss
Lack of energy
Heat intolerance
Anxiety/irritability

Question 23

what are the signs of hyperthyroidism

Answer 23

Tremor
Warm, moist skin
Tachycardia
Brisk reflexes
Eye signs

Question 24

what are the symptoms of Symptoms of thyroid eye disease (TED)

Answer 24

Mild’ symptoms:

‘itchy’ / dry eyes
Artificial tears help
‘prominent’ eyes

worse symptoms :
Diplopia / loss of sight
Loss of colour vision
Grey  / blurred patches
Redness / swelling of conjunctiva

Question 25

Give 2 signs for each area of the body for hyperthyroidism Neck, hands, pulse and eyes

Answer 25

Hands:
Fine tremor
Warm

Pulse:
Sinus tachycardia
Atrial fibrillation

Neck:
Goitre
Move when swallow

Eyes
Lid retraction / lid lag
Proptosis / exophthalmos

Question 26

what is the cause of autoimmune thyrotoxicosis

Answer 26

Autoantibody stimulates the
TSH receptor, causing excess
thyroid hormone production
and thyroid growth (goitre)

Question 27

what are the other causes of thyrotoxicosis

Answer 27

Toxic multinodular goitre
Toxic adenoma
Thyroiditis
Drugs (e.g. amiodarone)

Question 28

how to differentiate between graves and normal hyperthyroidism

Answer 28

• Personal or family history of any autoimmune thyroid / endocrine disease
• Goitre with a bruit = Graves disease
• Thyroid eye disease = Graves disease (20%)
• Positive thyroid autoantibody titre

Question 29

Further investigations

Answer 29

Thyroid autoantibodies

Thyroid uptake scan (isotope scan)
Functional scan: darker areas of increased activity

Question 30

what are the treatment options for graves disease

Answer 30

Medical

Radioiodine

Surgery

Symptom control
β-blockers (propranolol)
Not if asthmatic

Risks of no treatment
Symptoms worsening
Atrial fibrillation
Stroke
Osteoporosis
Fractures

Question 31

what can RADIOIODINE be used for

Answer 31

Oral treatment, radioiodine concentrated in thyroid, radiation kills thyroid cells
Medical therapy first till euthyroid

Question 32

Treatment for a toxic adenoma or toxic multinodular goitre

Answer 32

Initial treatment: short term medical therapy (to control thyroid function tests)

Subsequent curative treatment: radioiodine

Question 33

how can you treat thyroid eye disease

Answer 33

• Steroids
• Pulsed IV methylpred / oral prednisolone
• Other immunosuppressive / steroid-sparing agents
• Radiotherapy

Question 34

what is Thyroid storm

Answer 34

Multi-system
Graves
Goitre, thyroid eye disease
hyperpyrexia

CNS
Agitation, delirium

Cardiovascular
Tachycardia >140 bpm
Atrial dysrhythmias
Ventricular dysfunction
Heart failure

GI
Nausea & vomiting
Diarrhoea
Hepatocellular dysfunction

Question 35

when would you consider thyroiditis

Answer 35

Consider if:
Patient is pregnant / within 1 year post-partum
 risk T1 diabetes, FHx thyroid disease, smoker

Patient has very tender thyroid

Clinical thyroid status does not fit with lab results-rapidly changing TSH and long hypo operiod
(Rapidly changing thyroid function tests)

No diagnostic features of Graves disease

Current / recent treatment with immunomodulatory medication

Question 36

Association of autoimmune thyroid disease with other diseases

Answer 36

Type 1 diabetes
Pernicious anaemia
Coeliac disease

Turner syndrome
Down’s syndrome

Addisons disease

Medication for other diseases
Lithium
Inhibits thyroid hormone synthesis & secretion
Amiodarone