CBL 7. A PATIENT WITH DIZZINESS Flashcards
A 34-year-old woman presents to her GP with a three month history of tiredness, such that it was affecting her work as she was always late getting up, and frequently falls asleep at work. She also notes some weight gain. Her GP wonders about a thyroid problem.
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Q1. Outline your clinical assessment of a patient who you suspect has thyroid
problems.
What are the important points in the history and examination?
COME BACK
History:
- Weight changes (increase)
- Timeline
- Bowel habits
- Temperature
- Hair loss & outside of eyebrows (hypo)
- Mood (low in hypo /
- Periods
- Skin (dry in hypo)
Describe examination of thyroid
Inspection:
- Masses
What investigations would you do in someone who presents with tiredness? [7]
FBC: check for anaemia
TFTs & specific antibody tests
HbA1C: DM
Pregnancy test
Pernicious anaemia: anti-IF andB12 and folate deficiency
Coeliac screen
ESR or CRP: malignancy
Vitamin D levels
Cortisol levels - adrenal
Name and explain three drugs that can cause hypothyroidism [2]
Lithium: decreases thyroid hormone synthesis and blocks thyroid hormone release
Amiodarone contains a high iodine load, which can interfere with thyroid hormone synthesis
Radiotherapy
How do you determine if raised lymph nodes is caused by malignancy or infection? [1]
Infection: tender / painful LN
Malignancy: non-tender / painless
State risk factors for hypothyroidism [5]
Iodine deficiency
Female sex
Middle age (30-50)
Autoimmune thyroiditis
Autoimmune disorders
Tx for hyperthyroidism
Post partum thyroiditis
Name two genetic disorders that increases risk of hypothyrodism [2]
Turners syndrome
Downs syndrome
How can you determine how far a goitre extends to? [1]
Percuss from top of thyroid to chest
Which autoimmune disorders are associated with hypothyrodism [6]
Vitiligo
Sjogren’s syndrome
MEN deficiency:
- Hypoparathyroidism
- adrenal failure
- ovarian failure
- DMT1
Blood tests:
TSH 56.5 mIU/l (0.6-6.0)
Free T4 7.0 pmol/L (9-20)
Interpret the blood results. How would you treat and monitor this patient?
Low T4; High TSH: hypothyroidisim
How often do you monitor TFTs in patient with hypothyroidism levels? [2]
New levothyroxine / every dose change:
* follow up every 3 months
Once TFTs are stable:
- Check annually
Her GP notes she had some areas of depigmentation on her forearms, but otherwise examination is normal.
What is the relevance of the depigmentation over the forearms? [1]
Vitiligo: depigmentation of melanocytes
Shows that predisposed to autoimmune conditions
Her GP prescribes levothyroxine and assures her she will feel better within a few weeks. In fact she begins to feel worse. Whilst she loses a bit of weight, her tiredness persists and she starts to feel nauseated and dizzy as she gets out of bed in the morning.
Q3. Was it reasonable for her GP to assure her she would feel better once getting levothyroxine replacement? Why might she be feeling worse?
AEs of levothyroxine:
- Thyrotoxicosis / Hyperthyroidism symptoms
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She continues to work, until whilst travelling on the underground in the morning during
her commute she collapses, and is taken to the Emergency Department. Witnesses
said she became very pale, collapsed but did not have a seizure. Examination findings
in the Emergency Department are shown below.
Examination:
Alert, but looks unwell, looks tanned, JVP not visible
Pulse 108 bpm
Lying BP 104/75 mmHg
Sitting BP 82/60 mmHg
Saturations 99% room air
Capillary blood glucose 3.2 mmol/L
Q3. What does this clinical assessment suggest? [2]
What is your differential diagnosis? [4]
Hypoglycaemia: < 4 blood glucose
Postural hypotension: lying to sitting SBP drops by 30 mmHg; DBP drops by 10-15 mmHg
Differential diagnosis for collapse:
* Diabetes & insulin users
* Cardiac problem
* Overdose of drugs
* Addisonian crisis
Initial investigations came back showing the following
Q4. How does this help with your diagnosis?
Explain the biochemical abnormalities
Deranged Na & K
Deranged U&Es
Addisonian crisis:
* hyponatraemia; and hyperkalaemia due to lack of cortisol and aldosterone
