Thyrotoxicosis

Question 1

Definition

Answer 1

The clinical effect of ↑T4, usually from gland hyperfunction.

Question 2

Symptoms

Answer 2

Diarrhoea
  ↑ appetite but ↓ wt.
  Sweats, heat intolerance
  Palpitations
  Tremor
  Irritability
  Oligomenorrhoea ± infertility

Question 3

Signs on the hands

Answer 3

Fast / irregular pulse
Warm, moist skin
Fine tremor
Palmer erythema

Question 4

Signs on the face

Answer 4

Thin hair
Lid lag
Lid retraction

Question 5

Signs on the neck

Answer 5

Goitre or nodules

Question 6

Graves specific signs (3)

Answer 6

Opthalmopathy, dertmopathy, thyroid acropatchy

Question 7

Explain the opthalmopathy

Answer 7

Exophthalmos
Ophthalmoplegia: esp. up-gaze palsy Eye discomfort and grittiness
Photophobia and ↓ acuity
Chemises - conjunctival oedema

Question 8

Explain the dermopathy

Answer 8

pre-tibial myxoedema

Question 9

Investigations

Answer 9

↓TSH, ↑T4/↑T3
  Abs: TSH receptor, TPO
  ↑Ca, ↑LFTs
  Isotope scan
  ↑ in Graves’
  ↓ in thyroiditis
  Ophthalmopathy: acuity, fields, movements

Question 10

Epidemiology of Grave’s

Answer 10

60% of cases of thyrotoxicosis
Prev: 0.5%
Sex: F»M=9:1
Age: 40-60yrs

Question 11

Features of Graves

Answer 11

Diffuse goitre ̄c ↑iodine uptake
Ophthalmopathy and dermopathy
Triggers: stress, infection, child-birth

Question 12

Associations

Answer 12

T1DM
Vitiligo
Addison’s

Question 13

Other causes of thyrotoxicosis

Answer 13

Toxic Multinodular Goitre = Plummer’s Disease, toxic adenoma, thyrotoxic phase of thyroiditis, drugs

Question 14

What is Plummer’s disease?

Answer 14

Toxic Multinodular Goitre = Plummer’s Disease
Autonomous nodule develops on background multinodular goitre.
Elderly and iodine-deficient areas
Iodine scan shows hot nodules

Question 15

What is a toxic adenoma

Answer 15

Solitary hot nodule ± producing T3/T4

Most nodules are non-functional

Question 16

what is thyrotoxic pass of thyroiditis

Answer 16

Hashimoto’s
de Quervain’s
Subacute lymphocytic

Question 17

Drugs leading to thyrotoxicosis

Answer 17

e.g amiodarone, thyroxine

Question 18

Medical treatment

Answer 18

Symptomatic: β-B (e.g. propranolol 40mg/6h)
Anti-thyroid: carbimazole (inhibits TPO)
Titrate according to TFTs or block and replace In Graves’ Rx for 12-18mo then withdraw
~50% relapse → surgery or radioiodine SE: agranulocytosis

Question 19

Radiological treatment

Answer 19

Most become hypothyroid

CI: pregnancy, lactation

Question 20

Surgical treatment and complications

Answer 20

Thyroidectomy
Recurrent laryngeal N. damage → hoarseness Hypoparathyroidism
Hypothyroidism

Question 21

Features of a thyroid storm

Answer 21

↑temp
  Agitation, confusion, coma
  Tachycardia, AF
  Acute abdomen
  Heart failure

Question 22

Precipitants

Answer 22

Recent thyroid surgery or radio-iodine
Infection
MI
Trauma

Question 23

Treatment

Answer 23

1. Fluid resuscitation + NGT
2. Bloods: TFTs + cultures if infection suspected
3. Propranolol PO/IV
4. Digoxin may be needed
5. Carbimazole then Lugol’s Iodine 4h later to inhibit thyroid
6. Hydrocortisone
7. Rx cause