Tutorial 3 - Thyroid Disorders Flashcards
(14 cards)
CASE 1
Woman
25-year old
Presents to her GP
Presenting Complaint/History of PC/Examination
- She was upset about divorce
- Wanted something to calm her down and help her sleep
- She had been very irritable for the last 18 months
- History of palpitations over past year
- Weight loss over past year
- Sweating over the past year
- She had noticed a swelling in her own neck over the past year
- Fine tremor
- Looked thin
- Pulse = 112bpm
- Blood Pressure = 106/70 mmHg
- A mass in the centre of her neck, which was soft, extended symmetrically either side of the midline
- Mass not tender to touch.
- This mass moved with swallowing.
- She had bilateral exophthalmos (prominent eyes).
Family History
- Recently divorced
- Two aunts had neck operations
What is the likely diagnosis based on the history and examination?
[CASE 1]
Grave’s Disease (autoimmune disease)
This was causing hyperthyroidism
What investigations do you want to do?
[CASE 1]
Check antibodies
- stimulatory antibodies
Blood Test for T3/T4 and TSH
- would expect low TSH and high T4 in primary hyperthyroidism
Imaging via radioiodine uptake can
- radioiodine taken up by thyoid gland
- measure uptake
- hot area in Grave’s Disease
- you would get a diffuse, increase uptake [not nodular]
What other signs might you see in her eyes?
[CASE 1]
Lid-lag
- up to down test to see if there is a delay
- see white of eyeballl move before lid moves in Grave’s Disease
- if bad enough, lid may retract and not fully close and the eye would dry up in this case, causing corneal scarring and chemosis
What is chemosis?
[CASE 1]
Red eye
Swelling (or edema) of the conjunctiva.
It is due to the oozing of exudate from abnormally permeable capillaries
What treatment is required?
[CASE 1]
Surgery
- subtotal thyroidectomy
- then give thyroxine (T4)
- curative
- may also lose parathyroids
- it’s invasive and leaves a scar
- could affect voice by damaging the recurrent laryngeal nerve
Radioiodine
- takes up lots of nuclear iodine
- destroys thyroid gland
- effect of surgery without having surgery
- have to avoid people for 8 days due to the 8 day half-life of radioiodine
- may have to be off work for a month if you work with children or pregnant women
PTV/Caberysol
- anti-thyroid
- inhbits thyroid peroxide
Beta-Blockers
- reduce cardiac symptoms (e.g. heart rate and palpitations)
- help her sleep
- help tremor
What is an average normal pulse?
[CASE 1]
60-100 bpm
How do you look for a tremor?
[CASE 1]
Ask patient to stretch out their hand
Place paper on top of their hand
What are the patient’s signs/symptoms of Grave’s Disease?
[CASE 1]
- Low BP
- Tachycardic
- Swelling
- Palpitations
- Family history
- Tremors
- Sweating
- Thyroid moves on swallowing
- Bilateral exopthalmos (see lots of the whites of eyes)
CASE 2
Woman
32-year old
Presents to GP
Presenting Complaint/History of PC/Examination
- progressive tiredness over the last 2 years since the birth of her daughter
- She wants a vitamin preparation to give her more energy.
- constipated
- intolerant of the cold
- one stone heavier than before the birth of her child
- periods were now much heavier and lasted longer than ever.
- pale
- increased BMI
- appeared disinterested in GP’s questions
- pulse = 54 bpm
- BP = 110/75 mmHg
- slow relaxing reflexes
Family History
- 2 year old daughter
- Ischaemic heart disease in her family
Social History
- Let go from her job as a cashier in Sainsbury’s 6 months ago because her throughput of customers had slowed so much
What is the likely diagnosis?
[CASE 2]
Primary Hypothyroidism
What investigations do you want to carry out?
[CASE 2]
Blood test for T3/T4 and TSH
Would expect:
- high TSH
- low T4
What treatment is required?
[CASE 2]
Thyroxine (T4)
Primary hypothyroidism occurs when the thyroid gland itself fails. What is secondary hypothyroidism?
[CASE 2]
Low TSH and Low T4 due to a failure of the pituitary
