thyroid disease

Question 1

1. Hyperthyroidism- DDX

Hypothyroidism - DDx

Answer 1

Hyperthyroidism- DDX

1. Grave’s disease
2. subacute thyroiditis- painful
3. postpartum thyroiditis- painless
4. toxic nodular goiter
5. toxic multinodular goiter
6. infectious thyroiditis - painful
7. haemorrhage in thyroid nodule- painful

Hypothyroidism - DDx

1. Hashimoto’s thyroiditis
2. iodine deficiency
3. Li+ induced thyroiditis
4. Amiodarone induced thyroiditis
5. radiation and surgery

Question 2

2. hyperthyroidism- C/F and physical exam

Answer 2

C/F

1. Increase energy
2. insomnia
3. heat intolerance
4. increase appetite and wt loss
5. diarrhoea

Physical examination

1. tremor
2. tachycardia
3. hypertension
4. hyperreflexia

Question 3

3. Hypothyroidism- C/F and Physical examination

Answer 3

C/F

1. tiredness/lethargy
2. sleeping, depression
3. cold intolerance
4. decrease appetite, weight gain
5. constipation
6. huskiness of voice
7. hair loss

Physical examination

1. bradycardia
2. hypotension
3. hyporeflexia
4. thin hair
5. hypercholesterolaemia- xanthoma, xanthelasma

Question 4

Thyroid investigations - thyroid Ab

Answer 4

1. TOP: Thyroid peroxidase enzyme
   - Hashimoto’s thyroiditis
   - subacute thyroiditis
   - postpartum thyroiditis
2. TRAB: thyroid receptors Ab –> Grave’s disease
3. anti- TG: anti-thyroglobulin –> for thyroid cancer

Question 5

Thyroid investigation- Thyroid nucleotide scan

Answer 5

only for hyperthyroidism
C/I in pregnancy
stop breastfeeding for 3 days post-test

interpretation

• cold nodule–> consider FNA
• hot nodule (heterogeneous uptake) –> toxic nodular/multinodular goiter
• diffuse homogenous uptake –> Grave’s disease

Question 6

name of test to rule out thoracic outlet obstruction

Answer 6

Pemberton sign

Question 7

Grave’s disease treatment

Answer 7

1. propranolol 10mg BD
2. Carbimazole 10-45mg/day in 2-3 doses

if 1st trimester pregnant: PTU 200-6600 mg/day in 2-3 doses

3. surgery: thyroidectomy
4. radiation: Radioactive iodine
   
   • women: no pregnancy for 6 months
   • men: no conception for 4 months (new sperm in 3 months)
   • all: avoid contact with children and pregnant women for several days

Question 8

Subacute Thyroiditis - treatment

Answer 8

1. Propranolol 10mg BD
2. Aspirin 300mg daily OR Ibuprofen 400mg PO TDS
3. prednisolone 40mg daily, tapering over 4 weeks

Question 9

Hypothyroidism treatment and follow up

Answer 9

1. Thyroxine 50mcg daily, titrate up dose while follow up
   a. Hashimoto’s thyroiditis
   b. Subclinical hypothyroidism when TSH >10
   c. Subclinical hypothyroidism when TSH 4-10 with TPO +ve
   d. 1st trimester when TSH > 2.5 regardless of overt or subclinical hypothyroidism

     In IHD, Thyroxine 25mcg daily 

2. Repeat TSH for follow up when comence thyroxine
   - 6 weeks after starting thyroxine
   - Then every 3 months for 1st year
   - Then annual follow up
3. If aiming to increase:
   - increase by 30-50% of total daily dose
   - In IHD, increase 25mcg every 6 weeks

Question 10

Hypothyroidism- indication for referral

Answer 10

1. Age < 18 years
2. pregnant
3. IHD
4. nodule
5. no response to treatment

Question 11

Grave’s disease- eye manifestation

Answer 11

1. exophthalmos
2. ophthalmoplegia
3. pretibial myxoedema
4. clubbing
5. lid lag retraction

Question 12

hyperthyroidism - associated other diseases

Answer 12

1. T1DM
2. Addision disease
3. vitiligo

Question 13

Hypothyroidism - associated other diseases

Answer 13

1. Turner disease
2. down syndrome
3. cystic fibrosis
4. primary biliary cirrhosis