-
causes of thyrotoxicosis? (5)
- graves
- multinodular goitre
- toxic adenoma
- thyroiditis
- pituitary adenoma
-
clinical presentation of someone with thyrotoxicosis?
- weight loss
- dyspnoea
- sweating/heat intolerance
- fatigue
-
signs on a thyroid exam of thyrotoxicosis?
- AF/sinus tachy
- fine tremor
- lid lad
- eye protrusion
- palmar erythema
- hyperreflexia
-
what antibodies are found in thyrotoxicosis?
TSH receptor antibodies on thyroid
-
which is preferred to scan thyroid activity:
A) 99m-technetium
B) radio-I
A
-
what abnormalities are found on blood tests for thyrotoxicosis?
- DM
- LFTs raised
- hypercalcaemia
- glycosuria
-
what do you give for the AF/tachy in someone waiting for TFT results?
beta blockers
-
first line treatment for thyrotoxicosis?
carbamizole
-
side effect of carbamizole?
what do you watch out for then?
- agranulocytosis
- watch for sore throat or rash
-
what is the drug treatment for thyrotoxicosis if the patient is pregnant?
propylthiouracil
-
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?
thyroid storm
-
symptoms of thyroid storm?
-
percentage mortality of thyroid storm?
10%
-
treatment for thyroid storm?
EMERGENCY!
- fluids
- abx
- propanolol
- sodium ipodate/dexamethasone/amiadorone
- carbimazole
-
what does the sodium ipodate/dexamethasone/amiadorone given in emergency treatment of thyroid storm do?
lowers T3
-
what thyroid problems can occur in pregnancy and the year following?
- thyrotoxicosis
- with thryoditis
- graves and also anti-TPO antibodies
-
what is de Quervain's thyroiditis?
what causes it?
- painful goitre due to thyroiditis
- post-infection
subacute 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?
yes
-
what is the commonest cause of thyrotoxicosis?
graves
(it is triggered by infection)
-
which antibody is raised in grave's?
- IgG
- against the TSH receptor
-
what signs are seen in a thryoid exam that are specific to grave's?
- periorbital oedema
- exophthalmos
- diplopia from ophthalmoplegia
- thyroid acropachy
- pre-tibial myxoedema
- goitre with bruit
-
what is the sex and age of onset of graves?
40yo female
-
dermal myxoedema (not the pre tibial of grave's) is seen in hypo/hyperthyroidism?
hypo
-
you get clonus in hypo or hyperthyroidism?
hyperthyroidism
-
you can get hoarseness and carpal tunnel syndrome in hypo/hyperthyroid?
hypo
-
angina/heart failure and ankle swelling is assoc with hypo/hyper?
hyper
-
what is the sex ratio of hypothyroidism?
6female:1male
-
where in the world has the highest prevalence of hypothyroidism?
- mountains: himalayas, andes
- probs because of dietary I deficiency
-
common causes of hypothyroidism?
- hashimoto's
- any treatment for hyperthyroidism
- dietary iodine deficiency
- amiadorone
-
what infiltrative diseases can sometimes cause hypothyroidism?
- sarcoid
- amyloid
- Reidel's thyroiditis
-
hair thinning, depression, malar flush and menorrhagia are sometimes seen with hypo/hyperthyroid?
hypo
-
how does the ECG change with hypothyroidism?
-
what is the treatment for hypothyroidism?
what do you give if the patient has heart failure?
- T4
- 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?
hypothyroid coma
-
what is a hypothyroid coma?
- EMERGENCY
- reduced consciousness
- hypothermia
-
what does the CSF show in hypothyroid coma?
- raised proteins
- raised pressure
-
how do you treat a suspected hypothyroid coma case?
- EMPIRICALLY
- T3 oral prefs
- hydrocort (you assume there is adrenal insufficiency too)
rewarming/fluids/abx/oxygen
-
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?
multinodular goitre
-
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?
1000
-
risk factor for hashimotos?
age
-
what happens in hashimoto's to the thyroid?
- TPO-antibodies
- lymphoid infiltration of the thyroid -> fibrosis
-
what abnormalities in the blood in someone with hashimoto's?
- ANF
- antibodies against TPO
-
what malignancy is hashimoto's linked to?
lymphoma
-
does someone with hashimoto's have a goitre?
yes
-
treatment for hashimoto's?
thyroxine
-
what is toxic adenoma?
which thyroid cells
TFTs
- solitary follicular adenoma of thyroid
- autonomously produces thyroxine
- TSH is low
-
what is the commonest thyroid malignancy?
papillary ca
-
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?
follicular ca
-
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?
medullary ca
-
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?
40yo female
-
what kind of thyroid malignancy can elderly women get? (2)
-
name a non-malignant cause of a slow-growing, hard, irregular goitre?
riedel's thyroiditis
-
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
- malignancy
-
FHH
lithium
thyrotoxicosis
->cause what to calcium?
hypercalcaemia
-
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?
FHH
-
what if calcium is high but PTH is not?
cancer
CT and myeloma screen needed
-
treatment for hypercalcaemia?
- IV saline - renal function
- IV bisphosphonates - to stop bone resorption
- SC/IM calcitonin
-
name three bisphosphonates
- pamidronate
- zoledronic acid
- clodronate
-
how common is hypocalcaemia?
rare
-
what is the effect of acute pancreatitis on calcium?
hypocalcaemia
-
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?
- tetany
- triad of carpopedal spasm, stridor, convulsions
- trousseau's sign
- chvostek's sign
- papilloedema
-
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
- 800
- women are twice as likely
- >50yo
-
what tumour syndrome is primary hyperPTH linked to?
MEN
-
what is osteitis fibrosa?
- complication of hyperPTH
- causes fractures and bone deformities
-
name 4 complications of hyperPTH?
- osteitis fibrosa and osteoporosis
- complication of hyperPTH
- pseudogout
- nephrocalcinosis
-
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
c) PTH
- a) increases it
- b) decreases
- c) normal
-
treatment for FHH?
NONE needed
-
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
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