Thyroid disease
Station 2 or Station 5:
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"This lady has been presented with...
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Puffy / swollen eyes
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Neck lump
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Sweating / Palpitations / Anxiety / Tremor"
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(in other words - symptomatic thyrotoxicity)​
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History-taking:​
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Thyroid eye disease:
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Visual loss or reduction in visual acuity
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Eye pain, redness & swelling
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Diplopia (double vision) - may be in pattern of complex ophthalmoplegia
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Difficulty closing their eyes, when severe can lead to exposure keratitis in severe cases
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Red flag symptoms warrant an urgent, same day assessment by ophthalmology:
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Diplopia / complex ophthalmoplegia
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Significant visual loss
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Red desaturation – suggestive of optic neuritis
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Neck lump:
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Duration: chronic goitres tend to be benign, does not mean they don’t need treatment!
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Size – has the lump changed in size since it was first noticed?
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Malignant thyroid nodules tend to grow faster
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Compressive symptoms:
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Difficulty swallowing or speaking
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Symptomatic thyroid disease:
- Patients will volunteer their most obvious presenting symptom
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Ask about most common presenting symptoms as per the table below:
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Key tip
With limited time in PACES, assessing thyroid status thoroughly is challenging
Have a systematic approach for thyroid assessment so you can quickly and fluently assess thyroid status
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Consider:
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‘Top to toe’ approach
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Systems-based approach – cardiovascular, respiratory, gastrointestinal etc.
Examination
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Thyroid eye disease
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Inspection from front, side and above
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Exophthalmos
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Lid retraction
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Lid lag on rapid downward gaze
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Assess eye movements for ophthalmoplegia
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Look for diplopia not in keeping with an isolated cranial nerve pathology e.g. CN III palsy
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Assessment of visual acuity
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Offer to use a Snellen chart
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Neck lump
Inspection
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For goitre or thyroidectomy scar
Palpation
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From behind for goitre, size, shape, tenderness
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Swallow assessment
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Regional lymph node examination
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Auscultate
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For bruits – these occur due to increased blood flow to an enlarged, overactive thyroid in thyrotoxicosis patients, but are rare in clinical practice
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Thyroid status examination
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Hands
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Warm & sweaty
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Fine tremor
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Cold, dry skin
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Thyroid acropachy (sometimes known as pseudo-clubbing)
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Pulse
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Heart rate or AF
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Legs
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Proximal myopathy (more often hyperthyroidism but difficult to differentiate from general fatigue from hypothyroidism)
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Delayed deep tendon reflexes (hypo)
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Pretibial myxoedema (hypo
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Key tip
Patients who have had a thyroidectomy are perfect for PACES.
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Don't forget that even if a patient has had a thyroidectomy in the past, often residual tissue may be left or not excised at the time of surgery.
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This remaining tissue can be the source of recurrent symptoms, so don't discount thyroid disease purely on the basis of a thyroidectomy in their past medical history
Investigations
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Thyroid function tests (TFTs)
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Thyrotoxicosis – low TSH, high T3/T4
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Hypothyroidism – high TSH, low T3/T4
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Subclinical hypothyroidism – high TSH, normal T3 and T4
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Subclinical hyperthyroidism – low TSH, normal T3 and T4
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Subclinical hyperthyroidism is associated with an increased risk of developing atrial fibrillation and osteoporosis, and still warrants treatment.
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TSH receptor antibodies (TRABs)
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Positive in Graves’ disease
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Can help to differentiate between Graves’ cisease and toxic multinodular goitre.
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Management
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Thyroid eye disease
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Supportive management
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Topical lubricants for patients at risk of exposure keratitis
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Selenium may improve thyroid eye disease
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Medical management​
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High dose prednisolone (60mg) for thyroid eye disease
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Can be started same-day in severe cases whilst awaiting urgent ophthalmology assessment
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Immunotherapies e.g. rituximab
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Specialist / surgical management
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Orbital radiotherapy
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Orbital decompression surgery – often a ‘last resort’ however may be performed urgently if there are any sight-threatening features
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Hyperthyroidism
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Symptomatic treatment with propranolol
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Weaned as symptoms improve
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Helps to decrease conversion to T4 peripherally
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Definitive treatment: Carbimazole or Propylthiouracil​
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Titration regime – High dose carbimazole or propylthiouracil is titrated to thyroid response
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‘Block + replace’ regime – the patient is given high dose carbimazole alongside thyroxine
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Patient counselling:
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Carbimazole is relatively contraindicated in women of childbearing age, pregnancy or breastfeeding, therefore propylthiouracil is preferred
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Risk of agranulocytosis with carbimazole. Patients should be advised to seek medical attention if they develop a severe sore throat
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Graves disease
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Approximately 33% of Graves’ Disease patients will only need one course of treatment
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Relapses occur in 66% and are treated with radioactive iodine or surgical thyroidectomy
Toxic multinodular goitre:
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Radioactive iodine
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Radioactive iodine is taken up by the toxic nodules whilst the rest of the thyroid maintains normal function
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Patients are required to isolate for two weeks post-treatment
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Contraindicated in thyroid eye disease
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Hypothyroidism
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Levothyroxine supplementation
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Check lipid levels: cholesterol may be raised in hypothyroidism.
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This often resolves once levothyroxine is started and thyroid function is optimised
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Hypercholesterolaemia only requires treatment if lipids remain high after TFTs normalise
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Patient counselling
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Levothyroxine should be taken on an empty stomach, half an hour before food. This is due to its interaction with calcium (reduces absorption of levothyroxine). A common reason for persistence of symptoms despite levothyroxine therapy is concurrent use of a calcium supplement
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Common examiner questions
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What are the possible causes of thyrotoxicosis?
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Graves’ Disease (autoimmune)
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Toxic multinodular goitre
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Single thyroid adenoma
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Thyroiditis (post-partum, post-viral illness)
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Drugs – amiodarone, lithium, over-the-counter drugs (seaweed/iodine)
What are the differential diagnoses for a thyroid neck lump?
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Thyroid cancer – neck lump will usually grow faster, and may have malignant symptoms like fatigue, unintentional weight loss and night sweats, along with difficulty swallowing, a persistent sore throat and pain in the front of the neck.
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Often not associated with systemic symptoms of thyrotoxicosis or hypothyroidism.
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Multinodular goitre
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Thyroid adenoma
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Single nodule