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81 Cards in this Set
- Front
- Back
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What is the most sensitive and preferred test for thyroid dysfunction?
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TSH |
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What are the raised autoantibodies antimicrosomal or antithyroid peroxidase suggestive of?
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Hashimoto thyroiditis (autoimmune thyroiditis) |
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What are antithyroglobulin, antithyroid peroxidase and TSH receptor antibodies elevated in? |
*TSH receptor antibody is very specific for Graves |
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What is the single most cost-effective investigation for diagnosis of thyroid nodules? |
Fine needle aspiration |
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What is the significant of a functioning nodule on a thyroid isotope scan? |
A functioning nodule is said to be less likely to be malignant than a non-functioning nodule (cyst, colloid nodule, haemorrhage are non-functioning; carcinoma is usually non-functioning) |
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When is USS useful in thyroid disease?
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More sensitive in dectection of thyroid nodules Can differentiate between a thyroid nodule and multinodular goitre Goitre less likely to be malignant Can be used for follow up nodules Can also differentiate a solid from a cystic mass |
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When is a CT scan useful in thyroid disease?
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Can also use for follow up of above |
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What patients are more at risk for developing hypothyroidism?
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Previous Graves disease Other autoimmune disorders e.g RA, T1DM Down syndrome Turner syndrome Drugs: lithium, amiodarone, interferon Previous thyroid or neck surgery Previous radioactive iodine rx of thyroid |
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Tiredness + husky voice + cold intolerance = |
Myxoedema (hypothyroidism) |
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Name at least 7 symptoms of hypothyroidism (myxoedema)? |
Constipation Cold intolerance Lethargy/ somnolence Physical slowing Mental slowing Depression Huskiness of voice Puffiness of face and eyes Pallor Loss of hair Weight gain |
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Name 8 clinical signs you might see on examination in person with hypothyroidism? |
Sinus bradycardia Delayed reflexes (normal muscular contraction, slow relaxation) Course, dry and brittle hair Thinning of outer third of eyebrows Dry, cool skin Skin pallor or yellowing Obesity Goitre |
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What is the commonest cause of bilateral non-thyrotoxic goitre in Australia? |
Hashimoto thyroiditis (autoimmune thyroiditis) |
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What 3 features might you find in a patient with Hashimoto thyroiditis? |
Bilateral grove Classically described as firm and rubbery thyroid Patients may be hypothyroid or euthyroid with a possible early period of thyrotoxicosis |
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How do you confirm the diagnosis of Hashimoto thyroiditis? |
A strongly positive antithyroid microsomal antibody titre and/ or FNA cytology |
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What tests might you consider on a suspected hypothyroid patient? What levels would you expect? |
T4 - subnormal TSH - Elevated (>10 is clear gland failure) Serum cholesterol - elevated FBC - anaemia (usually normocytic, may be macrocytic) ECG - sinus brady, low voltage, flat T waves |
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What should you exclude before starting T4 replacement? And why? |
Coexisting hypoadrenalism and ischaemic heart disease * Treatment as primary hypothyroidism when hypopituitarism is the cause may precipitate adrenal crisis |
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What medication is used as treatment of hypothyroidism? |
Thyroxine 100-150 mcg daily * Start low in elderly and pts with IHD (25-50 mcg) |
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Name 4 contraindications to starting thyroxine |
Untreated hyperthyroidism Uncorrected adrenal insufficiency Thyrotoxicosis Acute MI uncomplicated by hypothyroidism |
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Name at least 1 side effect of thyroxine from each system of the body |
Cardiovascular - Chest pain, tachycardia, cardiac arrhythmias, palpitations, angina, myocardial ischaemia, myocardial infarction, heart failure, death. Nervous system - Irritability, anxiety, nervousness, excitability, restlessness, tremors, headache, poor concentration, emotional lability, sleep disturbance, insomnia, mania, psychosis, psychotic depression, seizures, petit mal status epilepticus, pseudotumour cerebri (especially in children). Gastrointestinal system - Diarrhoea, vomiting, malabsorption.Skin. Warmth, erythema, telangiectasia, hyperhidrosis, alopecia, hyperpigmentation. Respiratory system - Increased minute ventilation, tachypnoea, and shortness of breath. Neuromuscular system - Myopathy, lid lag, muscle weakness and cramps. Reproductive system - Amenorrhoea, menstrual irregularities, decreased libido, gynaecomastia (in male). Metabolic - Fever, glucose intolerance, weight loss, premature craniosynostosis (in children), TRH suppression, heat intolerance, sweating, flushing. |
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Name at least 5 common drugs that thyroxine interacts with |
Oral anticoagulants e.g. Warfarin SSRIs e.g. sertraline Insulin and anti diabetic agents e.g. sulphonureas Beta-blockers e.g. propanalol Corticosteroids e.g. prednisolone Antibacterials e.g. ciprofloxacin |
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What levels of TSH are you aiming for? How often should you monitor? |
0.5-2 mU/L Monitor monthly at first When euthryorid 2-3 monthly When stable monitor every 2-3 years Lifelong rx |
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What are some special treatment considerations for hypothyroidism? |
IHD - rapid thyroxine replacement can precipitate MI esp. in elderly Pregnancy and post partum - continue during, many need higher levels of thyroxine as can become hypothyroid Elective surgery - if euthyroid can stop rx, if sub thyroid defer until euthyroid Myxoedema coma - urgent hospitalisation |
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What is the most common type of hyperthroidism (thyrotoxicosis)? |
Graves disease * Followed by nodular thyroid disease |
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What are the 5 other causes of hyperthyroidism? |
Autonomous functioning nodules Subacute thyroiditis (de Quervain thyroiditis) - viral origin Excessive intake of thyroid hormones - thyrotoxicosis factitia Iodine excess Amiodarone |
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Anxiety + weight loss + weakness = |
Thyrotoxicosis |
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What 7 symptoms might a patient with hyperthyroidism complain of? |
Heat intolerance Sweating of hands Muscle weakness Weight loss despite normal or increased appetite Emotional lability, esp. anxiety, irritability Palpitations Frequent loose bowel motions |
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What signs (other than eye ones) might you find in a patient with hyperthyroidism? |
Agitated, restless patient Warm and sweaty hands Fine tremor (place paper on hands) Goitre Proximal myopathy Hyperactive reflexes Bounding peripheral pulse +/- AF |
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Name the 4 eye signs you might find in a patient with hyperthyroidism? |
Lid retraction (small area of sclera seen above iris) Lid lag Exophthalmos Ophthalmoplegia in severe cases |
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What investigations would you consider in a patient with suspected hyperthyroid disease? What might you find? |
T4 (and T3) - elevated TSH - suppressed Radioisotope scan - uniform increased uptake in Graves disease, irregular in toxic multi nodular goitre, poor or no in Quervain thyroiditis and thyrotoxicosis factitia Antithyroid peroxidase |
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What treatment options are available for hyperthyroidism? |
Radioactive iodine therapy Thionamid antithyroid drugs (initial doses) - carbimazole 10-45mg daily - Propylthiouracil 200-600mg daily Adjunctive drugs - beta blockers e.g. propanolol 10-40mg 6-8 hrly (for symptoms in acute florid phase) - lithium carbonate (rarely used - only when intolerance to thionamides - Lugol's iodine - mainly used prior to surgery Surgery - subtotal or total thyroidectomy |
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What might influence your selection of treatment for Graves disease? |
Younger pt with small goitres and mild case - 18 month course of antithyroid drugs Older patients with small goitres - as above or radioiodine (preferably when euthyroid) Large goitres or mod-severe cases - antithyroid drugs until euthyroid then surgery of radioactive iodine rx |
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What treatments are generally considered for autonomous functioning nodules? |
Control hyperthyroidism with antithyroid drugs, then surgery or radioactive iodine rx *Long term remission with just antithyroid drugs in a toxic nodular goitre are rare |
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What are the features of subacute thyroiditis? |
Pain and/or tenderness over the goitre (esp. swallowing) Fever Usually follows viral illness |
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What treatments are generally considered for subacute thyroiditis? |
Rest Analgesics (aspirin 600mg QID-TDS) Soft foods If pain severe consider corticosteroids Can use b-blocker for symptom control |
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What are the 3 contraindications to carbimazole therapy? |
Previous adverse reactions to carbimazole Serious pre-existing haematological condition Severe hepatic insufficiency |
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Name at least 5 adverse effects of carbimazole |
Nausea, mild GI upset; headache; arthralgia; loss of taste; rash; pruritus; urticaria; bone marrow depression, haematological disturbances eg agranulocytosis (discontinue); hepatic disorders eg abnormal LFTs, hepatitis, cholestatic hepatitis, jaundice (discontinue); myalgia, myopathy (monitor CPK); angioedema, multisystem hypersensitivity eg cutaneous vasculitis, hepatic, lung, renal effects |
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What 3 medications can carbimazole interact with? |
Agranulocytosis inducing drugs Anticoagulants Theophylline |
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What is the one contraindication to propylthiouracil? |
Thioamide hypersensitivity |
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What are the common adverse effects of propylthiouracil? |
Haemopoietic effects eg agranulocytosis, granulocytopenia, leucopenia, thrombocytopenia; hypothyroidism; itching; dizziness; joint pain; loss of taste; GI upset; peripheral neuropathy; hypersensitivity incl rash; rare: hepatotoxicity, vasculitis |
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What medications can propylthiouracil interact with? What investigations should you consider |
Oral anticoagulants, heparin; agranulocytics lab tests: prothrombin time, LFTs |
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What are the clinical features of thyroid crisis (thyroid storm)? |
Marked anxiety Weight loss Weakness Proximal muscle weakness Hyperpyrexia Tachycardia (>150 bpm) Heart failure Arrhythmias |
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What are the 3 causes of thyroid nodules? |
Dominant nodule in multinodular goitre (most likely) Colloid cyst True solitary nodule: adenoma, carcinoma (pappillary or follicular) |
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What are the 3 main presentations in thyroid carcinoma? |
Painless nodule A hard nodule in an enlarged gland Lymphadenopathy |
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What is the most common type of thyroid carcinoma? |
Papillary carcinoma |
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What are the 3 main groups of presentation with pituitary tumours? |
1. Hormone deficiencies 2. Features of hypersecretory syndromes e.g. prolactin, GH, ACTH 3. Local tumour mass symptoms e.g. headache, visual field loss |
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What are the main causes of hyperprolactinaemia? |
Pituitary adenoma (micro or macro) Pituitary stalk damage Drugs e.g. antipsychotics, antidepressants, metoclopramide, cimetidine, oestrogens, opiates, marijuana Pregnancy and breastfeeding |
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What symptoms might be experienced in hyperprolactinaemia? |
Reduced libido Sub-fertility Galactorrhoea (mainly females) Amenorrhoea/ oligomenorrhoea Erectile dysfunction |
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What investigations would you consider for hyperprolactinaemia? |
Serum prolactin and macroprolactin assays MRI: consider if headache etc. |
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What management options are available for hyperprolactinaemia? |
Refer for management May include a dopamine agonist such as cabergoline or bromocriptine |
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Nasal problems + fitting problems (e.g. rings or shoes) + sweating = |
Acromegaly |
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What investigations would you consider in the diagnosis of acromegaly? |
Plasma growth hormone excess Elevated insulin-like growth factor 1 (IGF-1) (somatomedin) - the key test MRI scanning pituitary Consider associated impaired glucose tolerance/ diabetes |
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Weakness + polyuria + polydipsia = |
Diabetes insipidus |
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What are the causes of diabetes insipidus? |
Postoperative - commonest and transient only Tumours Infections Infiltrations |
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What is the treatment for diabetes insidious? |
Desmopressin usually given BD intranasally |
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Female: amenorrhoea + loss of axillary and pubic hair + breast atrophy = |
Hypopituitarism |
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Male: decreased libido + impotence + loss of body hair = |
Hypopituitarism |
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How do you investigate hypopituitarism? |
Serum pituitary hormones Imaging Triple test stimulation |
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Fatigue + anorexia/ nausea/ vomiting + abdominal pain +/- skin discolouration = |
Addison disease |
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What is the most common cause of Addison disease? |
Autoimmune destruction of the adrenals |
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What investigations would you consider in the diagnosis of Addison disease? |
Elevated serum potassium, low serum sodium Low plasma cortisol level (fails to respond to ATCH) Short synacthen stimulation test - definitive test Consider - adrenal autoantibodies - imaging ?calcification of adrenals |
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What are the 5 main causes of Cushing syndrome? |
Iatrogenic - chronic cortiocosteroid administration Pituitary ACTH excess (cushing disease) Bilateral adrenal hyperplasia Adrenal tumour (adenoma, adenocarcinoma) Ectopic ACTH or (rarely) corticotrophin-releasing hormone (CRH) from non endocrine tumours e.g. oat cell carcinoma of lung |
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Plethoric moon face + thin extremities + muscle weakness = |
Cushing syndrome |
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Name at least 7 clinical features of Cushing syndrome |
Proximal muscle wasting and weakness Central obesity, buffalo hump on neck Cushing facies: plethora, moon face, acne Weakness Hirsuitism Abdominal striae Thin skin, easy bruising HTN Hyperglycaemia (30%) Menstrual changes e.g. amenorrhoea Osteoporosis Psychiatric changes esp. depression Backache |
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What investigations should you consider in the diagnosis of Cushing syndrome? |
Cortisol excess (plasma or 24 hour urinary cortisol) Dexamethasone suppression test Serum ACTH Radiological localisation: MRI for ACTH-producing pituitary tumours, CT for adrenal tumours |
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What is the most common cause of primary hyperaldosteronism? |
Adrenal adenoma |
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Usually hyperaldosteronism is asymptotic but if they do experience symptoms what might you expect? |
Features of hypokalaemia - weakness - cramps - paraesthesia - polyuria and polydypsia |
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What investigations should you consider in hyperaldosteronism? |
Aldosterone (serum and urine) increased Plasma renin decreased Na Increased K decreased Alkalosis |
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What is a pheochromocytoma? |
A dangerous tumour of the adrenal medulla |
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What are clinical features of pheochromocytoma? |
HTN Headache (throbbing) Sweating Palpitations Pallor/ skin blanching Rising sensation of tightness in upper chest and throat (angina can occur) |
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What investigations should you do for pheochromocytoma? |
Series of three 24 hour free catecholamines increased VMA Abdominal CT or MRI |
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What treatment options are there for pheochromocytoma? |
Excise tumour Cover with alph and beta blockers |
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What should you do with adrenal tumours >4cm? |
Thorough assessment as malignant tumours are large |
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Weakness + constipation + polyuria = |
Hypercalcaemia |
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Cramps + confusion + tetany = |
Hypocalcaemia |
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What causes of hypercalcaemia account for over 90% of cases? |
Primary hyperparathyroidism Familial hypercalciuric hypercalcaemia Neoplasia esp. lung and breast with bone mets |
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What investigations would you consider in hypercalcaemia? |
ESR - for sarcoidosis Serum PTH Serum ACE levels Serum akaline phosphatase CXR Sestamibi scan Bone scan |
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Bones, moans, stones and abdominal groans = |
Primary hyperparathyroidism |
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What investigations would you consider in hyperparathyroidism? |
Exclusion of other causes of hypercalcaemia Serum PTH (elevated) TC-99m Sestamibi scan to detect tumour |
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What are 2 important signs in hypocalcaemia? |
Trousseau sign: occlusion of the brachial artery with BP precipitates carpopedal spasm (wrist flexion and fingers drawn together) Chvostek sign: tapping over parotid (facial nerve) causes twitching in facial mucles |
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What are treatment options for hypocalcaemia? |
Calcitriol and calcium - careful balance |
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What is the most common cause of hypocalcaemia? |
Hypoparathyroidism Others include: postoperative thyroidectomy and parathyroidectomy, congenital deficiency (Di George syndrome) and idiopathyic (autoimmune) hypoparathyroidism |
