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RE > Thyroid Disease > Flashcards

Thyroid Disease Flashcards

1
Q

Assessment of the Thyroid Gland:

A

Structural Assessment:
- normal size
- reduced/absent
- ectopic
- enlarged -> goitre
- physiological enlargement:
- adolescence
- pregnancy
- pathological enlargement

Functional Assessment:
- euthyroid
- hypothyroid
- hyperthyroid (thyrotoxic)

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2
Q

What is the preferred imaging modality for the thyroid gland?

A

ultrasound

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3
Q

Thyroid Gland Development:
- maturity?
- why is maternal thyroid
supply to the foetus
important in the first
trimester?

A
  • maturity by week 11-12
  • thyroxine production by week
    16
  • important for neurological
    development
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4
Q

What is thyroid agenesis?

A
  • developmental problem
  • congenital hypothyroidism
  • cretinism
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5
Q

What is aberrant thyroid?

A
  • developmental issue
  • ectopic thyroid gland
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6
Q

What are thyroglossal cysts?

A
  • developmental issue
  • midline neck cysts
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7
Q

Congenital Hypothyroidism:

A
  • 1 in 4000 births
  • universal screening in heel-
    prick blood test
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8
Q

Thyroid Gland Developmental:

A

insert diagram

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9
Q

TFTs:

A
  • thyroid function tests
  • TSH, FT4, FT3
  • free thyroid hormones
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10
Q

Hypothyroidism: TFTs:

A
  • TSH (high)
  • Free T4 (low)

rider is forcing horse, horse isnt working

hypothalamus and pituitary producing more TRH, TSH but thyroid gland not responding and not producing T4

hence inhibitory negative feedback loop is not completed and hypothalamus/pituitary is not inhibited

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11
Q

Hyperthyroidism: TFTs:

A
  • TSH (high)
  • Free T4 (high)
  • Free T3 (high)
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12
Q

Which TFT is the initial investigation of choice?

A
  • TSH
  • TSH is slow to respond to
    changes in thyroid status and
    takes around six weeks for
    levels to equilibrate after
    changes
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13
Q

TSH results can be misleading for:

A
  • secondary/central
    hypothyroidism
  • non-thyroidal illness
  • recent treatment for
    thyrotoxicosis
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14
Q
A

insert image above normal TFT results

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15
Q

Regulation of Thyroid Hormones:

A

insert image

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16
Q

Target organ for T3 and T4?

A

every cell

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17
Q

Ultrasound of Thyroid Gland:

A

insert image

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18
Q

What is the most common clinical problem of thyroid?

A

hypothyroidism

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19
Q

Hypothyroidism is more common in which sex?

A

10x more common in females

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20
Q

Thyroid Antibodies:

A
  • autoimmune antibodies exist
    in the population -> not
    everyone will develop thyroid
    disease
  • eg: Thyroid Peroxidase OAb
  • cause of thyroid disease: TSH
    receptor Ab
  • TPO antibodies increase risk
    of hypothyroidism in the next
    10 years
  • positive autoAb result =
    confirmation
  • negative autoAb result does
    not mean pt is clear of
    autoimmune disease
  • can lead to both hypo and
    hyperthyroidism
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21
Q

Hypothyroidism Symptoms:

A
  • none
  • lethargy
  • weight gain
  • constipation
  • **cold intolerance
  • facial puffiness
  • dry skin
  • hair loss
  • hoarseness
  • heavy menstrual cycle

**onwards = specific and severe
others are non-specific

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22
Q

Hypothyroidism Signs:

A
  • changes in facial appearance
  • puffy, pale skin
  • periorbital oedema
  • dry, flaking skin
  • diffuse hair loss
  • carpal tunnel
  • effusions
  • relayed reflex relaxation
  • croaky voice
  • goitre

**bradycardia, rare but can be in stupor or coma

** specific and severe
rest are non-specific

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23
Q

Features of Hypothyroidism:

A

insert image

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24
Q

Hypothyroidism: common Clinical Presentations:

A
  • Other Risk Factors:
    • other autoimmune disorders
      like T1DM, coeliac disease
    • family history
    • immune therapy for cancer:
      melanoma
  • Postpartum thyroiditis:
    • 10% women, 8-20 weeks
      postpartum
    • mostly self-limiting
  • Thyrotoxicosis:
    - post-surgery
    - post-radioiodine
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25
Q

Primary Hypothyroidism: Causes:

A

thyroid gland decreased function

  • autoimmunity
  • infection (thyroiditis)
  • drug interactions
  • congenital hypothyroidism
  • iodine deficiency
  • post hyperthyroidism
    treatment
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26
Q

Primary Hypothyroidism: TFTs:

A
  • TSH = high
  • T4 = low
  • T3 = low

due to decreased thyroid function, less T4 and hence T3 circulating, which means negative feedback loop not completed, resulting in high TSH levels

insert diagram

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27
Q

Secondary Hypothyroidism: Causes:

A

disease of pituitary or
hypothalamus

  • pituitary tumours
  • tumours compressing
    hypothalamus
  • sheehan syndrom (pituitary
    necrosis postpartum)
  • TRH resistance
  • TRH deficiency
  • lymphocytic hyophysitis
  • radiotherapy
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28
Q

Secondary Hypothyroidism: TFTs:

A
  • TSH = low
  • T4 = low
  • T3 = low

secondary hypothyroidism is when there is a disease of the pituitary or hypothalamus

hence TRH/TSH production is limited

hence can not stimulate thyroid gland to produce T4 hence low T3

insert diagram

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29
Q

Which type of hypothyroidism is most common?

A

Primary hypothyroidism is most common

30
Q

Hypothyroidism: Treatment:

A
  • core drug: levothyroxine (T4)
  • daily 1.6mcg/kg
  • standard treatment
  • Liothyronine (T3):
  • rare cases
  • short half-life
31
Q

Core Drug: Levothyroxine:
- half life and biological effect
- dose variations for which
categories
- monitoring
- when to take dose

A
  • 7-10 days, much longer
    biological effect
  • lower dose on elderly, 25-30%
    higher dose during pregnancy
  • repeat TSH test in 4- weeks
  • aim for 2mU/L
32
Q

Core Drug: Levothyroxine: Side Effects:

A
  • nausea
  • vomiting
  • diarrhoea
  • headaches
  • restlessness
  • flushing/sweating
  • muscle cramps
  • shaking
  • anxiety
  • arrhythmias
33
Q

Core Drug: Levothyroxine: Interactions:

A
  • amiodarone (treats
    arrhythmias)
  • antacids
  • digoxin
34
Q

Myxoedema (coma):

A
  • severe hypothyroidism
  • endocrine emergency with
    high mortality

Clinical Features:
- confusion
- hypothermia
- bradycardia, hypotension,
hypoglycaemia
- peripheral oedema

Precipitants: infection, stroke, heart failure

35
Q

Myxoedema (coma) Treatment:

A
  • supportive/ICU
  • Levothyroxine
  • sometimes T3
  • Steroids: IV hydrocostisone
36
Q

Hyperthyroidism: Symptoms:

A
  • lack of energy
  • heat intolerance
  • anxiety/irritability
  • increased sweating
  • thirst
  • pruritus
  • oligomenorrhoea

**weight loss associated with increased appetite, palpitations, loose bowels

**specific vs non-specific

37
Q

Hyperthyroidism: Signs:

A
  • tremor
  • warm and moist skin
  • tachycardia
  • brisk reflexes
  • eye signs
  • thyroid bruit
  • muscle weakness
  • atrial fibrillation
38
Q

Hyperthyroidism Features:

A

insert image

39
Q

Thyrotoxicosis: Causes:

A
  • Grave’s Disease (autoimmune)
  • thyroiditis
  • toxic multinodular goitre
  • toxic adenoma
  • drug induced: amiodarone,
    lithium
40
Q

Thyrotoxicosis: Presentations:

A
  • classic symptoms:
  • investigate other illnesses
  • thyroid eye disease
  • post-partum

Other biochemical changes:
- Liver: transaminitis (high AST,
ALP, ALT)
- Bone: high ALP,
hypercalcaemia
- Pancytopenia/Neutropenia
(confusion etc)

41
Q

Hyperthyroidism: Causes: Grave’s Disease:

A
  • accounts for 75% of
    autoimmune hyperthyroidism
  • autoantibody Ig that binds to
    thyroid epithelial cells
    mimicking the stimulatory
    action of TSH
  • binding is to thyrotropin TSH
    receptor
  • activity of the thyroid is
    increased
  • Levels of T4 and T3 increase,
    and the thyroid grows (goitre)
42
Q

What is shown below?

A

Grave’s thyroiditis

gland is diffusely enlarged, fleshy and dark coloured due to increased vascularity

43
Q

Hyperthyroidism: TED/TAO:

A
  • Thyroid Eye Disease/ Thyroid
    Associated Ophthalmopathy
  • inflammation of all orbital
    tissues except eye = muscle,
    eyelids, conjunctiva
  • itchy, dry eyes
  • prominent appearance
    change
  • diplopia
  • loss of colour vision
  • redness and swelling of
    conjunctiva
  • inability to close eyes
  • aching and pain behind the
    eyes
  • proptosis
  • ptosis

associated with autoimmune hyperthyroidism

44
Q

What is shown below?

A

Thyroid Eye Disease

45
Q

Hyperthyroidism: Nodules:

A
  • toxic refers to the
    overproduction of thyroid
    hormones
  • toxic adenoma = region of
    abnormal growth termed a
    nodule which can be solid or
    fluid filled
  • toxic multi-nodular goitre =
    multiple nodules
  • both lead to generation of
    excess thyroid hormones
  • usually benign, rarely
    cancerous
46
Q
A

insert diagram

47
Q

Hyperthyroidism: Causes: Thyroiditis:

A

insert slide

48
Q

Hyperthyroidism: Grave’s Disease: Treatment:

A

First Line:
- radioiodine
- surgery

Risks of no treatment:
- symptoms escalate
- atrial fibrillation
- osteoporosis

Symptomatic control:
- Propranolol (beta blocker)
***if not asthmatic

49
Q

Core Drug: Levothyroxine: Drug Class:

A

Thyroid Hormones

50
Q

Hyperthyroidism: Medical Therapy:

A
  • anti-thyroid drugs:
  • carbimazole
  • propylthiouracil
  • course of therapy: 18-24
    months
  • monitor reduction in T4 and
    T4

Two options:
1) start with high conc
carbimazole and reduce dose
as thyroid function settles
2) continue high dose
carbimazole and then add
thyroxine

Long term medication to reduce relapse

51
Q

Core Drug: Carbimazole:
- drug class
- mechanism of action

A
  • antithyroid drugs
  • inhibitors of thyroid
    peroxidases: TPO or iodide
    peroxidase
52
Q

Core Drug: Propylthiouracil (PTU):
- drug class
- mechanism of action

A
  • antithyroid drugs
  • inhibitors of thyroid
    peroxidases: TPO or iodide
    peroxidase
53
Q

Core Drugs: Carbimazole and Propylthiouracil: Side Effects:

A
  • *Agranulocytosis rare but high
    mortality
  • 1-2 months
  • 2 weeks to resolve
  • sore throat, mouth ulcer,
    infection
54
Q

Hyperthyroidism: Treatment: Radioiodine Treatment (RAI):

A
  • medical treatment employed
    first
  • until patient is euthyroid
  • oral treatment
  • I 131 concentrates in thyroid
    gland
  • beta radiation destroys cells
    (ablation)

**patient is radioactive hence
must avoid others for 2
weeks

55
Q

Hyperthyroidism: Srugery:

A
  • total or sub-total
    thyroidectomy
  • generally with large goitres

Risks:
- anaesthetic
- neck scar (cosmetic)
- hypothyroidism
- hypoparathyroidism
- vocal cord palsy due to
recurrent laryngeal nerve
damage

56
Q

Hyperthyroidism: Adenoma/Multi-toxic Goitre: Treament:

A
  • initial medical treatment
  • controls thyroid function tests
  • curative treatment via
    radioiodine treatment I131
57
Q

Hyperthyroidism: Thyroid Eye Disease: Treatment:

A
  • management of thyrotoxicosis
    is vital
  • immunosupressive
  • steroid/steroid-sparing agents
  • radiotherapy

Surgical:
- orbital decompression
- eyelid surgery

58
Q

Thyrotoxic Crisis:

A
  • very rare complication
  • usually in pts with Grave’s
    Disease
  • high mortality
    risk/acute/medical emergency
  • triggers: erratic compliance
    with treatment, surgery,
    pregnancy, acute severe
    illness

Severe symptoms:
- CVS: tachycardia>140bpm,
arrhythmia, heart failure
- CNS: low GCS, agitation,
delirium
- GI: nausea, vomiting,
deranged LFTS

59
Q

Thyrotoxic Crisis: Management:

A

insert slide

60
Q

Grave’s Disease is an —– reaction to —- receptor.

A
  • autoimmune
  • TSH receptor
61
Q

Thyroid nodules are detected in up to 65% of the general population.

True or False?

A

True

62
Q

Thyroid nodules are mostly benign and insignificant findings.

True or False?

A

True

63
Q

Goitre:

A

insert slide

64
Q

Goitre Management:

A

insert flowchart

65
Q

Thyroid Gland

A

insert diagrams

66
Q

Examination of the Thyroid:

A

insert slide

67
Q

Hypothyroidism: Investigations and Management:

A

insert diagram

68
Q

Thyrotoxicosis: Investigations and Management:

A

insert slide

69
Q

Thyroid Nodule: Investigations and Management:

A

insert slide

70
Q

TFTs and Causes

A

insert diagram

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