causes of thyrotoxicosis? (5)
- multinodular goitre
- toxic adenoma
- pituitary adenoma
clinical presentation of someone with thyrotoxicosis?
- weight loss
- sweating/heat intolerance
signs on a thyroid exam of thyrotoxicosis?
- AF/sinus tachy
- fine tremor
- lid lad
- eye protrusion
- palmar erythema
what antibodies are found in thyrotoxicosis?
TSH receptor antibodies on thyroid
which is preferred to scan thyroid activity:
what abnormalities are found on blood tests for thyrotoxicosis?
- LFTs raised
what do you give for the AF/tachy in someone waiting for TFT results?
first line treatment for thyrotoxicosis?
side effect of carbamizole?
what do you watch out for then?
- watch for sore throat or rash
what is the drug treatment for thyrotoxicosis if the patient is pregnant?
non-pharmacological treatment for thyrotoxicosis?
- radioactive iodine
- surgery to remove thyroid (best outcome)
name an emergency complication of thyrotoxicosis brought on with 131-I or surgery?
symptoms of thyroid storm?
percentage mortality of thyroid storm?
treatment for thyroid storm?
- sodium ipodate/dexamethasone/amiadorone
what does the sodium ipodate/dexamethasone/amiadorone given in emergency treatment of thyroid storm do?
what thyroid problems can occur in pregnancy and the year following?
- with thryoditis
- graves and also anti-TPO antibodies
what is de Quervain's thyroiditis?
what causes it?
- painful goitre due to thyroiditis
which infections could cause de quervain's syndrome?
what sex and age of onset is average for de quervain's thyroiditis?
what is the course of the symptoms of de quervain's thyroiditis?
- 1. hyperthyroidism
- 2. hypothyroidism
- 3 euthyroid (6 months ish)
how do you treat de quervain's thyroiditis?
- just treat the symptoms!
- beta blockers/pred/NSAIDs
what is subclinical hyper/hypothyroidism?
- TSH is abnormal
- but T3/4 is just within the range
- asymto for now
do you treat subclinical thyroid problems?
what is the commonest cause of thyrotoxicosis?
(it is triggered by infection)
which antibody is raised in grave's?
- against the TSH receptor
what signs are seen in a thryoid exam that are specific to grave's?
- periorbital oedema
- diplopia from ophthalmoplegia
- thyroid acropachy
- pre-tibial myxoedema
- goitre with bruit
what is the sex and age of onset of graves?
dermal myxoedema (not the pre tibial of grave's) is seen in hypo/hyperthyroidism?
you get clonus in hypo or hyperthyroidism?
you can get hoarseness and carpal tunnel syndrome in hypo/hyperthyroid?
angina/heart failure and ankle swelling is assoc with hypo/hyper?
what is the sex ratio of hypothyroidism?
where in the world has the highest prevalence of hypothyroidism?
- mountains: himalayas, andes
- probs because of dietary I deficiency
common causes of hypothyroidism?
- any treatment for hyperthyroidism
- dietary iodine deficiency
what infiltrative diseases can sometimes cause hypothyroidism?
- Reidel's thyroiditis
hair thinning, depression, malar flush and menorrhagia are sometimes seen with hypo/hyperthyroid?
how does the ECG change with hypothyroidism?
what is the treatment for hypothyroidism?
what do you give if the patient has heart failure?
- or T3 if you need a quicker acting drug when patient has HF
what are the consequences of hypothyroidism in pregnancy?
foetal brain development is hindered
what is a myxoedema coma aka?
what is a hypothyroid coma?
- reduced consciousness
what does the CSF show in hypothyroid coma?
- raised proteins
- raised pressure
how do you treat a suspected hypothyroid coma case?
- T3 oral prefs
- hydrocort (you assume there is adrenal insufficiency too)
what is sick euthyroid?
peripheral conversion of T4->T3 has gone awry due to a systemic illness
- low TSH
- high T4
- low/normal T3
what does a simple diffuse goitre develop into with age?
what is the age and sex of onset of simple diffuse goitre?
what are the symptoms of simple diffuse goitre?
none, it's aympto
what happens to the thyroid in multinodular goitre? what are the consequences?
- focal areas of hyperplasia/multiple adenomas
- autonomously secretes T4/T3
- this lowers TSH levels (subclinical hyperthyroidism) -> atrophy of the normal thyroid gland
- becomes toxic nodular goitre when thyroxine levels get high enough, and they will eventually
3.5 in how many people get hashimotos?
risk factor for hashimotos?
what happens in hashimoto's to the thyroid?
- lymphoid infiltration of the thyroid -> fibrosis
what abnormalities in the blood in someone with hashimoto's?
- antibodies against TPO
what malignancy is hashimoto's linked to?
does someone with hashimoto's have a goitre?
treatment for hashimoto's?
what is toxic adenoma?
which thyroid cells
- solitary follicular adenoma of thyroid
- autonomously produces thyroxine
- TSH is low
what is the commonest thyroid malignancy?
is cervical lymphadenopathy likely in:
a) papillary ca
b) follicular ca
c) medullary ca
which thyroid ca is encapsulated, likely to spread to the brain/bone/lungs but not to cervical lymph nodes?
which cells do medullary ca come from and what can they secrete?
parafollicular C cells
-> calcitonin, serotonin, ACTH, PGs
what two syndromes can medullary ca imitate clinically?
- carcinoid syndrome
- cushingoid syndrome
which thyroid ca is linked to MEN2 genetics?
can you use radioactive iodine to treat the following:
a) follicular ca
b) toxic adenoma
c) medullary ca?
- a) yes
- b) yes
- c) no - it's from the parafollicular cells
why do you give a patient with follicular ca of thyroid T3?
to suppress TSH production
what age and sex of onset of thryoid tumours/ca?
what kind of thyroid malignancy can elderly women get? (2)
name a non-malignant cause of a slow-growing, hard, irregular goitre?
what is Pendred's syndrome?
- autosomal recessive
- dyshormognesis -> low TPO
- also has sensorineural deafness
what happens in thyroid hormone resistance?
pituitary and hypothalamus are resistant to thyroxine feedback
common causes of hypercalcaemia?
- primary hyperPTH
->cause what to calcium?
clinical picture of hypercalcaemia?
- stones - renal colic
- bones - osteomalacia
- moans - lethargy, depression, reduced cognition
- abdominal groans - nausea, dyspepsia, peptic ulcers, constipation
describe secondary hyperPTH?
increased PTH because of chronic kidney disease and low vit D
describe tertiary hyperPTH?
high PTH for no reason after secondary PTH's low calcium/vit D has been corrected
what if there is hypercalcaemia and high PTH but urinary calcium is low?
what if calcium is high but PTH is not?
CT and myeloma screen needed
treatment for hypercalcaemia?
- IV saline - renal function
- IV bisphosphonates - to stop bone resorption
- SC/IM calcitonin
name three bisphosphonates
- zoledronic acid
how common is hypocalcaemia?
what is the effect of acute pancreatitis on calcium?
common cause of hypocalcaemia?
chronic kidney disease causing high phosphate levels
what does PTH do to calcium and phosphate?
- it increases serum calcium
- and increases phosphate excretion
clinical presentation of hypocalcaemia?
- triad of carpopedal spasm, stridor, convulsions
- trousseau's sign
- chvostek's sign
what does hypocalcaemia do to the ECG?
- prolonged QTC
- ventricular arrhythmias
what is trousseau's sign seen in hypocalcaemia?
carpal spasm less than 3mins after BP cuff
what is chvosteks sign in hypocalcaemia?
facial spasm when tapping the parotid gland (holds CVII)
what does vit D do?
increases serum calcium and phosphate
cause of primary hyperPTH?
single PTH adenoma
1 in how many people get primary hyperPTH?
age of onset and sex ratio
- women are twice as likely
what tumour syndrome is primary hyperPTH linked to?
what is osteitis fibrosa?
- complication of hyperPTH
- causes fractures and bone deformities
name 4 complications of hyperPTH?
- osteitis fibrosa and osteoporosis
- complication of hyperPTH
what causes a 'pepper pot' appearance on lateral Xrays of the skull?
- primary hyperPTH
- sub-periosteal erosions
what does cinacalcet given for tertiary hyperPTH do?
increases the sensitivity of the calcium receptor that the PTH gland is ignoring
explain the genetics of FHH?
what does it stand for?
familial hypocalciuric hypercalcaemia
auto dom mutation in the calcium receptor gene of PTH gland so it is desensitised to the negative feedback cycle
how does FHH affect:
a) serum calcium?
b) urinary calcium
- a) increases it
- b) decreases
- c) normal
treatment for FHH?
commonest cause of hypoPTH?
damage during thyroidectomy
name 3 familial causes of hypoPTH?
- diGeorge syndrome
- autosomal dominant hypoPTH (ADH)
- autoimmune polyendocrine syndome I
how do you treat hypoPTH?
- oral calcium
- SC PTH (but not if its pseudohypoPTH)
- nothing for A.D.H.
A)which familial syndrome causes inappropriately high PTH?
B) which familial syndrome causes inappropriate low PTH?
what is diGeorge's?
there is an activating mutation in the calcium sensor of the PTH gland so it thinks the levels are higher than they are
what is pseudohypoPTHism?
functionally hypoPTH but actually raised PTH levels
due to a PTH receptor resistance in the end organs
kids with a mutation in the MATERNAL chromosome
what is psudo-pseudoPTHism?
- serum calcium normal
- PTH normal
- clinical AHO (albright's)
kids with the mutation in the PATERNAL chromosome
what is AHO?
Albright's hereditary osteodystrophy
appears like they have hypoPTH; short, short 4th metatarsels/carpels, rounded face, obese
kids who have pseudo-pseudohypoPTH
what is the difference genetically between pseudohypoPTH and pseudo-pseudohypoPTH?
they are the same mutation!!!
this is an eg of genetic fingerprinting: it depends on if the gene is from the maternal or paternal chromosome