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Thyroid Disease Flashcards

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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
Primary Hypothyroidism: Causes:
thyroid gland decreased function - autoimmunity - infection (thyroiditis) - drug interactions - congenital hypothyroidism - iodine deficiency - post hyperthyroidism treatment
26
Primary Hypothyroidism: TFTs:
- 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
27
Secondary Hypothyroidism: Causes:
disease of pituitary or hypothalamus - pituitary tumours - tumours compressing hypothalamus - sheehan syndrom (pituitary necrosis postpartum) - TRH resistance - TRH deficiency - lymphocytic hyophysitis - radiotherapy
28
Secondary Hypothyroidism: TFTs:
- 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
29
Which type of hypothyroidism is most common?
Primary hypothyroidism is most common
30
Hypothyroidism: Treatment:
- core drug: levothyroxine (T4) - daily 1.6mcg/kg - standard treatment - Liothyronine (T3): - rare cases - short half-life
31
Core Drug: Levothyroxine: - half life and biological effect - dose variations for which categories - monitoring - when to take dose
- 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
Core Drug: Levothyroxine: Side Effects:
- nausea - vomiting - diarrhoea - headaches - restlessness - flushing/sweating - muscle cramps - shaking - anxiety - arrhythmias
33
Core Drug: Levothyroxine: Interactions:
- amiodarone (treats arrhythmias) - antacids - digoxin
34
Myxoedema (coma):
- severe hypothyroidism - endocrine emergency with high mortality Clinical Features: - confusion - hypothermia - bradycardia, hypotension, hypoglycaemia - peripheral oedema Precipitants: infection, stroke, heart failure
35
Myxoedema (coma) Treatment:
- supportive/ICU - Levothyroxine - sometimes T3 - Steroids: IV hydrocostisone
36
Hyperthyroidism: Symptoms:
- 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
Hyperthyroidism: Signs:
- tremor - warm and moist skin - tachycardia - brisk reflexes - eye signs - thyroid bruit - muscle weakness - atrial fibrillation
38
Hyperthyroidism Features:
insert image
39
Thyrotoxicosis: Causes:
- Grave's Disease (autoimmune) - thyroiditis - toxic multinodular goitre - toxic adenoma - drug induced: amiodarone, lithium
40
Thyrotoxicosis: Presentations:
- 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
Hyperthyroidism: Causes: Grave's Disease:
- 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
What is shown below?
Grave's thyroiditis gland is diffusely enlarged, fleshy and dark coloured due to increased vascularity
43
Hyperthyroidism: TED/TAO:
- 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
What is shown below?
Thyroid Eye Disease
45
Hyperthyroidism: Nodules:
- 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
insert diagram
47
Hyperthyroidism: Causes: Thyroiditis:
insert slide
48
Hyperthyroidism: Grave's Disease: Treatment:
First Line: - radioiodine - surgery Risks of no treatment: - symptoms escalate - atrial fibrillation - osteoporosis Symptomatic control: - Propranolol (beta blocker) ***if not asthmatic
49
Core Drug: Levothyroxine: Drug Class:
Thyroid Hormones
50
Hyperthyroidism: Medical Therapy:
- 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
Core Drug: Carbimazole: - drug class - mechanism of action
- antithyroid drugs - inhibitors of thyroid peroxidases: TPO or iodide peroxidase
52
Core Drug: Propylthiouracil (PTU): - drug class - mechanism of action
- antithyroid drugs - inhibitors of thyroid peroxidases: TPO or iodide peroxidase
53
Core Drugs: Carbimazole and Propylthiouracil: Side Effects:
- *Agranulocytosis rare but high mortality - 1-2 months - 2 weeks to resolve - sore throat, mouth ulcer, infection
54
Hyperthyroidism: Treatment: Radioiodine Treatment (RAI):
- 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
Hyperthyroidism: Srugery:
- 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
Hyperthyroidism: Adenoma/Multi-toxic Goitre: Treament:
- initial medical treatment - controls thyroid function tests - curative treatment via radioiodine treatment I131
57
Hyperthyroidism: Thyroid Eye Disease: Treatment:
- management of thyrotoxicosis is vital - immunosupressive - steroid/steroid-sparing agents - radiotherapy Surgical: - orbital decompression - eyelid surgery
58
Thyrotoxic Crisis:
- 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
Thyrotoxic Crisis: Management:
insert slide
60
Grave's Disease is an ----- reaction to ---- receptor.
- autoimmune - TSH receptor
61
Thyroid nodules are detected in up to 65% of the general population. True or False?
True
62
Thyroid nodules are mostly benign and insignificant findings. True or False?
True
63
Goitre:
insert slide
64
Goitre Management:
insert flowchart
65
Thyroid Gland
insert diagrams
66
Examination of the Thyroid:
insert slide
67
Hypothyroidism: Investigations and Management:
insert diagram
68
Thyrotoxicosis: Investigations and Management:
insert slide
69
Thyroid Nodule: Investigations and Management:
insert slide
70
TFTs and Causes
insert diagram

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