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Endocrine > Thyroid Clinical > Flashcards

Thyroid Clinical Flashcards

1
Q

What causes hypothyroid

A

Usually primary but can be 2
Hashiomoto’s = most common
Iodine deficiency
Lithium

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2
Q

What can cause hypo and hyperthyroid

A

Subacute thyroiditis
Post-partum thyroiditis - usually transient but presence of Ab makes it more likely to persist
Amiadarone

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3
Q

What causes hyperthyroid

A

Grave’s

Toxic multi nodular goitre

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4
Q

TSH and T4 levels primary hypothyroid

A

TSH =.high as trying to stimulate

T4 = low

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5
Q

Secondary hypothyroid

A 
TSH = low
T4 = low
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6
Q

Subclinical hypothyroid

A 
TSH = High - to maintain hormone 
T4 = normal but will become love
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7
Q

Poor compliance with thyroxine

A

TSH high

T4 normal

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8
Q

Grave’s / hyperthyroid

A

TSH low

T4 high

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9
Q

What are symptoms of hyperthyroid

A 
Increased BMR + heat 
production
- Weight loss
- Heat intolerance 
Increased protein catabolism
- Muscle weakness 
Increased CVS
- Tachycardia
- Palpitations
- HF due to increased CO / angina 
- AF
Hyper-reflexia
Autonomic Sx 
Increased appetite 
Bone resorption / osteoporosis 
Anxiety
Irritable 
Oligomenorrhoea
Sexual dysfunction 
Goitre 
Thyroid eye disease
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10
Q

What affect does Thyroid hormone have on CVS

A

Permissive to epinephrine

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11
Q

What are autonomic Sx

A

Sweating
Tremor
Diarrhoea

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12
Q

What are symptoms of hypothyroid

A 
Decreased BMR + heat 
- Weight gain
- Cold 
Disrupted protein 
- Thick skin
- Dry skin
- Dry coarse scalp hair
- Hair loss 
- Brittle nails
Dereased CVS
- Brady
- Oedema
Fluid retention = oedema, ascites, effusion 
Slow reflexes 
Carpal tunne
Depression
Aching joints  
Lethargy
Constipation 
Menorrhagia 
Giotre
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13
Q

What does severe hypothyroid cause

A 
Puffy face
Large tongue
Hoarse voice
Coma
Pleural effusion + oedema
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14
Q

What causes thyroid eye disease

A

Hypo or hyper

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15
Q

What are RF

A

Smoking

RAI

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16
Q

What are features

A

What are signs from least to most severe
Proptosis / exompthalos = same but used for Grave’s
Extra-ocular - opthamoplegia = paralysis
Corneal involvement
Sight loss
- Optic disc swelling

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17
Q

How do you Rx

A

Topical lubricant
Steroid
RT
Surgery

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18
Q

When do you get urgent ophthalmology review

A 
Unexplained deterioration in vision
Change in colour vision
Hx eye popping out (globe subluxation)
Corneal opacity
Cornea visible when eye closed
Disc swelling
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19
Q

What causes primary hypothyroid

A 
Congenital 
Autoimmune -Hashiomoto's
Iatrogenic
Chronic iodine deficiency 
Post subacute thyroiditis 'De Quervain's 
Somatostatin 
Glucocorticoids
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20
Q

What are iatrogenic causes

A 
Post thyroidectomy for hyperthyroid 
RAI
Anti-thyroid drugs
External RT
Lithium
Amiadarone
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21
Q

Congenital causes

A

Type 4

Maternal iodine deficiency

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22
Q

What is Hashimoto’s

A

Autoimmune destruction of thyroid gland
Cytotoxic T cells/ cytokines
Causes diffuse enlargement of gland / goitre to compensate
Can initially be hyperthyroid

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23
Q

What is associated with Hashimoto / Grave’s

A

DM
Addison’s
Pernicious anaemia

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24
Q

What Ab

A

Ab to thyroglobulin and thyroid peroxidase (TPO)

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25
Q

What causes secondary hypothyroid due to pituitary damage

A

Tumour
Craniopharyngioma
Post surgical Sheehan’s
Isolated TRH deficiency

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26
Q

What is subclinical hypothyroid

A

Mild symptoms but normal thyroid

Raised TSH to maintain at normal level

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27
Q

When do you consider treatment (don’t need to Rx )

A

If TSH >10
If TSH >5 with Ab present
Pregnancy
Symptomatic

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28
Q

What would overRx lead to

A

Osteoporosis
AF
as causes hyperthyroid

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29
Q

How do you investigate

A

TFT
Ab
Blood

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30
Q

What do you look for in blood of person with hypothyroid

A 
Macrocytic anaemia
Hyponatraemia due to SIADH if tumour
Hyper-Cholesterol
Hyper-Prolactin
Increased muscle enzymes
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31
Q

How do you Rx

A

Levothyroxine (T4)
Titrate until stable
If TSH low then T4 dose too high

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32
Q

What do you do if change dose

A

Check levels after 8-12 weeks of TSH

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33
Q

What are SE and what drugs affect absorption

A

Hyperthyroid
Reduced BMD
Worsening angina
AF

Iron affect absorption / food so take 30 mins before

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34
Q

What are special situations

A

If IHD start at lower dose as may precipitate angina by increasing HR
If pregnant may need increased dose

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35
Q

What causes primary hyperthyroid

A 
Grave's disease = most common
Toxic mulinodular goitre - 2nd most
Thyroid adenoma / solitary nodule 
De-Quervains following viral infection
Drugs - amiadarone
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36
Q

What are causes of secondary hyperthyroid

A

Pituitary adenoma secreting TSH = rare

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37
Q

What causes thyrotoxicosis without hyperthyroid

A

Destruction as release hormones
- Amiadarone
- Post partum
Excessive levothyroxine

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38
Q

What is Grave;s disease

A

Ab produced that mimics TSH and activates thyroid
TSH receptor Ab = 90%
Anti-thyroid peroxidase

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39
Q

What causes the thyroid eye disease in Grave’s

A

TSH receptor in ocular fibroblasts

40
Q

How does it present

A 
Signs of hyperthyroid
Diffuse goitre due to hyperplasia
Gynaecomastia
Clubbing
Nausea
Sweating
Eye disease - can cause corneal involvement / sight loss if optic nerve involved 
May have mild neutropenia
41
Q

What are signs of Grave’s NOT hyperthyroid

A 
Exophthalmos
Opthalmoplegia
Pretibial myxoedema - discoloured waxy deposit
Thyroid acropachy - clubbing, painful finger and toe swelling
Other autoimmune disease 
- Myasthenia gravis 
- Vitiligo 
- Pernicious anaemia
42
Q

How do you Rx Grave’s

A

Anti-Thyroid drugs
RAI
Surgery to remove but will be left hypothyroid requiring levothyroxine
BB for symptoms by blocking adnrenaline (slow HR and improve tremor and anxiety)

43
Q

What is most common regimen of anti-thyroid and what do you give after to destroy gland

A

Titration for 12-18 months
Can block replace - where block all then give thyroid
Carbimazole = 1st line
Propythiouracil

RAI

44
Q

What does carbimazole do

A

Blocks thyroid peroxidase so reduces production of hormone

Give in high dose till euthyroid then reduce

45
Q

What are SE

A

Agranulocytosis
Rash
Neutropenia so if develop infectious symptoms = urgent medical review

46
Q

What does propythiouracil do

A

Same
Also prevents conversion of T4-T3
RARE risk of liver reaction causing death

47
Q

When would you give long term low dose anti-thyroid

A

Elderly
Cardiac
Unwilling for RAI

48
Q

What are risks of RAI

A

Hypothyroid
No contact children / pregnancy for 4 weeks
No pregnancy 6 months
May worsen eye disease

49
Q

What is important in Hx of thyroid issue

A 
Symptoms of hyperthyroid 
Any previous thyroid issue or surgery
Any cardiac Sx
FH autoimmune
DH 
Any stress at home / depression
50
Q

Who is most common to get multi-nodular goitre

51
Q

What are symptoms

A

Characteristic goitre due to hyperplasia
Doesn’t listen to TSH and just releases hormones
Painless
Absence of Grave’s - no Ab

52
Q

How do you Dx

A

Nuclear scintigraphy

Main concern = malignancy but tend to be euthyroid

53
Q

How do you Rx

A

RAI or surgery if compression symptoms e.g. dysphagia or dyspnoea

54
Q

What is subclinical hyperthyroid

A

TSH suppressed but normal hormone

55
Q

What causes

A

Excessive thyroxine

Multi-nodular goitre

56
Q

What are concerns

A

Decreased bone density
AF
Dementia

57
Q

When do you treat

A

If elderly or cardiac risk

58
Q

What is subacute thyroiditis ‘De Quervain’s

A

Thyrotoxicosis for 3-6 weeks then hypothyroid

59
Q

What causes

A

Younger patient

Viral trigger - entero / coxsackie

60
Q

What are symptoms of thyrotoxicosis

A 
Raised ESR
Painful goitre
Fever
Myalgia
Dysphagia if compress
61
Q

How do you Rx

A

Self-limiting
NSAID for pain
BB for hyper Sx
Steroids if hypo develops

62
Q

What is a thyroid storm

A 
Life threatening complications of untreated severe thyrotoxiosis
Fever >38.5
Tachycardia
HTN 
Confusion
Agitation
N+V
Abdo pain 
HF
AF
Arrhythmia - can push into CCF
Abnormal LFT + jaundice
Seizure
63
Q

What precipitates

A 
Infection 
Surgery
Trauma
PE
DKA
PET
Acute iodine
64
Q

How do you Rx

A 
Admit to monitor 
Paracetamol
Treat underlying event
IV BB
May need fluid 
AA if AF 
Anti-thyroid - propylthiouracil
IV hydrocortisone e to prevent conversion from T4-T3
65
Q

How does hyper or hypo cause goitre and what should you think

A 
Hyper = overactivity e.g. Grave's 
Hypo = increased TSH due to hypo e.g. Hashimoto

Is it

  • Diffuse enlargement
  • Nodular
  • What is patients thyroid status
66
Q

What are physiological causes

A

Puberty

Pregnancy

67
Q

Wha are risk

A

Haemorrhage as highly vascular

68
Q

What are types of goitre

A 
Solitary thyroid nodule 
Multinodular 
Diffuse colloid
Diffuse simple
Cyst 
Tumour 
Sarcoid / TB
69
Q

What can tumour be

A

Adenoma
Carcinoma
Lymhpoma

70
Q

What does a solitary nodule in thyroid gland suggest if present along with

A 
Malignancy if 
Child
Adult <30 or >60
Painful
Previous head or neck RT
Cervical LN

More likely adenoma / cyst or discrete nodule in MNG

71
Q

What should you always do for large dominant nodule in multi-nodule

A

Investigate as 5% malignant

72
Q

How do you investigate

A 
TFT - TSH 
USS + FNA = 1st line if suspicious 
T4 and thyroid ab if abnormal 
Isotope scan 
CXR
73
Q

If hypo

A

Less likely malignant

74
Q

What are differentiated thyroid cancers

A

Papillary

Follicular

75
Q

What is most common and what is it associated with

A 
Papillary 
<50 
BRAF / RET gene
Exposure to radiation 
Multifocal
76
Q

Where does papillary spread and prognosis

A

Lymph so may present LN

Good prognosis

77
Q

How foes follicular present and what is association

A

Single lesion
Mets to lung / bone / blood
RAS mutation

78
Q

How do you manage differentiated tumour

A

REMOVE - thyroidectomy
DESTROY - High dose radio iodine
KEEP ASLEEP - long term thyroxine

79
Q

What suggests poor prognosis

A

<16 or >45
Tumour size
Spread outside capsule / mets

80
Q

How do you follow up

A

Thyroglobulin

Whole body isotope scan 2-5 weeks after withdrawal of thyroxin

81
Q

What are other cancers

A

Medulalry
Anoplastic
Lymhpoma

82
Q

Where does medullary arise from and what is it associated with

A

Parafollicular C cells
Malignant
MEN 2A+B / RET mutation
Raised calcitonin as produces

83
Q

How do you RX

A

Thyroiectomy

No RAI as not from thyroid cells

84
Q

Prongosis of anoplastic

A 
Aggressive
Locally invasive
Poor
No response to RAI
Rare
85
Q

How do you treat lymphoma

A

RT + chemo

Rare

86
Q

When is surgery likely and what do you give prior too prevent complications

A

Once euthyroid

Potassium iodide to reduce vascularity

87
Q

What are complications of surgery

A 
Bleeding
Trachea compression
Laryngeal nerve palsy
Hypocalcaemia
Hypothyroid
88
Q

What is important in Hx of lump

A 
Any dysphagia / sore throat / hoarseness
B symptoms
Appetite
Hx head or neck radiation
FH
Smoking / alcohol
89
Q

What is important in examinatio

A

Does it move on swallowing
Hard or soft
Irregular or regular
Fixed?

90
Q

What investigation is suspect thyroid origin of lump

A

TSH
Thyroid Ab
Thyroid USS
FNA

91
Q

How does myxoedema coma present

A

Severe hypothyroid
Confusion
Hypothermia
Other Sx related to slowing of organs e.g. brady

92
Q

How do you treat

A

IV thyroid
IV fluid
IV steroid until adrenal insufficiency excluded
Electrolyte imbalance correction

93
Q

What is sick euthyroid syndrome

A

Seen in hospital in sick patient
Low T3 an T4
TSH low or normal
Cortisol high as stress response

94
Q

How do you Rx

A

None as will recover when illness recovered

Recheck in 6-8 weeks

95
Q

How does amiadarone cause hypo and hyperthyroid

A 
Hypo = due to high iodine
Hyper Type 1 
- Increased hormone synthesis
- Goitre present
Hyper Type 2
- Destruction of gland
- No goitre
- Rx = steroid
96
Q

How do you treat destructive or post partum

A

Symptomatic BB as due to destruction of gland and release of hormones

Endocrine (17 decks)

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