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Diagnosis and Management of Common Thyroid Problems

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Management of hypothyroidism is a component of the Quality and Outcomes Framework. This self assessment resource is designed to test knowledge and understanding of the interpretation of thyroid disorders and thyroid function tests. Through a series of 10 assessment questions based upon typical clinical scenarios, the user will become familiar with the presentation of a variety of thyroid disorders including hypothyroidism and hyperthyroidism as well as interpretation of thyroid function test

To enable the user to have a better understanding of common thyroid disorders such as Graves' disease and Hypothyroidism together with subclinical hypo- and hyper- thyroidism.

To have a better understanding of the interpretation of thyroid function tests.

To have improved knowledge of the management of common thyroid problems.

http://www.cks.nhs.uk/clinical_knowledge/clinical_topics/previous_version/hypothyroidism.pdf

Guidelines on thyroid function tests - British Association for Clinical Biochemists 

http://www.acb.org.uk/docs/TFTguidelinefinal.pdf

Management of hypothyroidism is a component of quality outcomes framework. Through a series of 10 assessment questions based upon typical clinical scenarios, the user will become familiar with the presentation of a variety of thyroid disorders including hypothyroidism and hyperthyroidism as well as interpretation of thyroid function test

Enable the user to become familiar with common thyroid disorders such as Graves disease and Hypothyroidism together with subclinical hypo- and hyper- thyroidism.

Understand the management of common thyroid problems

A 45 year old woman attends clinic after seeing her GP wishing to discuss the results of her thyroid tests. She originally attended clinic complaining of feeling tired and having put on approximately 5kg in weight over the last one year. She informs you that she has a family history of thyroid problems, her mother had an underactive thyroid. After reading some articles on the internet, she now feels that she also has an underactive thyroid gland. She has no obvious abnormalities of note on examination. The results of thyroid function tests show:

Which of the following would be the most appropriate explanation of her results?

Patients often present with symptoms that could relate to an underactive thyroid gland (hypothyroidism) as symptoms such as weight gain and tiredness are very common. The thyroid function tests in this particular case reveal a normal T4 and also a normal TSH indicating that the thyroid is functioning normally euthyroidism. TSH is released from the anterior pituitary, and stimulates T4 release from the thyroid gland. T4 has a negative feedback on the TSH production, therefore the TSH is high in hypothyroidism, and is low in hyperthyroidism. TSH is a very specific and sensitive indicator of thyroid dysfunction. However, despite having normal thyroid function, some patients still continue to believe that they have an underactive thyroid.

http://www.patient.co.uk/doctor/Thyroid-Function-Tests-(TFTs).htm

Question 1

A 32 year old woman attends clinic, she is keen to know the results of her thyroid function tests that were performed a week ago. Over the last few months, she has been aware of a gradual weight gain and increasing tiredness. Her thyroid function tests show:

This patient has symptoms suggestive of hypothyroidism and her thyroid function tests support this, with low T4 and elevated TSH, indicating hypothyroidism. TSH is a hormone released from the anterior pituitary gland, and it stimulates the release of T4 from the thyroid gland. T4 then produces a negative feedback on the TSH production. However in this case, the T4 is low, therefore the TSH is increased to try to drive more T4 production from the thyroid gland. These are the typical results of hypothyroidism. The symptoms associated with this condition include weight gain, tiredness, constipation, dry skin, coarse dry hair as well as feeling cold.

http://www.patient.co.uk/doctor/Hypothyroidism.htm

Question 2

A 42 year old man is seen in clinic complaining of tiredness. There are no specific abnormalities to note on examination and his BMI is 31.2kg/m

. He has a number of blood tests undertaken and his thyroid function tests reveal:

Which of the following best describes these results?

In this case the patient was complaining of tiredness which lead to the assessment of his thyroid function. The free thyroxine (T4) level is normal, but the TSH level is high at 18.1mu/l indicating that the thyroid is beginning to tire necessitating the pituitary to produce more TSH to try to drive the production of T4 from the thyroid gland. This is called subclinical hypothyroidism. In general, a TSH above 10 requires treatment with thyroxine, this man should be treated.

http://www.patient.co.uk/doctor/Subclinical-Hypothyroidism.htm

Question 3

A 30 year old woman attends clinic for an annual assessment of her thyroid function. She is generally well but was diagnosed with hypothyroidism 2 years ago and is currently treated with thyroxine 50micrograms daily. Her thyroid function tests reveal:

You discuss compliance with her and she informs you that she regularly takes her medication.Which of the following would be the most appropriate management for this patient?

This patient appears to be slightly under-replaced with thyroxine, despite having a free T4 within the normal range the thyroid stimulating hormone (TSH) level remains elevated. The target of treatment is to have the TSH within the normal range. Thus, the patients dose of thyroxine should be increased by 25 micrograms initially, and repeat the thyroid function tests in approximately 6 weeks to assess for normalisation of the thyroid function tests.

Question 4

A 56 year old female attends clinic complaining of tiredness, ease of fatigue and weight gain over the last few months. She informs you that she has a strong family history of under active thyroid - both her mother and sister suffer from this problem. You think she has a diagnosis of hypothyroidism. Which of the following features on clinical examination would support the diagnosis?

Features of hypothyroidism include bradycardia, slow relaxation of tendon reflexes, coarse dry hair, and a typical puffy face and ruddy complexion. Fast heart rate, lid lag and exophthalmos (bulging of the eye anteriorly out of the orbit) are features of thyrotoxicosis. A goitre can be a feature of both hypothyroidism and thyrotoxicosis, but it is in thyrotoxicosis that you would hear the whoosh of blood going through the gland when you listen with a stethoscope which is termed thyroid bruit.

http://www.gpnotebook.co.uk/simplepage.cfm?ID=1174798342

Question 5

A 31 year old man attends clinic as he has been feeling really tired over the last one month. He was diagnosed one year ago with an overactive thyroid gland and 3 months ago received radioactive iodine treatment. His thyroid function tests reveal:

Which of the following would be the most appropriate treatment for this patient?

This patient has developed an under active thyroid (hypothyroidism) following the radio-iodine treatment. This is a common occurrence occurring in 80%+ of patients treated. The radioactive iodine often kills an excessive amount of thyroid cells, leaving the thyroid unable to produce enough hormones The low T4 and high TSH indicate this and so the patient should have thyroxine replacement and a dose of 100 micrograms could be started for this man.

http://www.patient.co.uk/doctor/Hyperthyroidism-(Thyrotoxicosis).htm

Question 6

A 45 year old male attends clinic complaining of sweats, heat intolerance and weight loss which have developed over the last three to four months. He has lost approximately 5kg in weight over this time. He has a history of hypertension for which he has been taking amlodipine, ramipril, simvastatin and aspirin.

On examination, he has sweaty palms and a pulse of 100 bpm regular. His BMI is 27 kg/m

 and blood pressure 130/76 mmHg. He has lid lag and slightly prominent eyes. He also has a goitre. His thyroid function tests reveal:

This man has symptoms and signs of an overactive thyroid gland, thyrotoxicosis and the eye signs suggest a diagnosis of Graves' disease. The thyroid function tests are confirmatory with a high T4 and suppressed TSH. Graves' disease is an autoimmune condition where antibodies are produced against the TSH receptor on the thyroid but instead of destroying the gland actually stimulate the gland causing it to over produce thyroxine. The autoantibody, TSH Receptor antibody can be requested on a blood test and is found in over 95% of cases of Graves disease. In this condition, eye signs such as exophthalmos and protuberance of the eyes (proptosis) can occur. The thyrotoxicosis can be treated with antithyroid drugs such as carbimazole and propylthiouracil, radioactive iodine or indeed surgery is indicated in some patients.

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001398/

Question 7

A 22 year old woman attends clinic for her annual thyroid function tests. She has a history of hypothyroidism for which she was prescribed 100 micrograms of thyroxine daily. There is no other history of note and she takes no other medication. She has no symptoms to report and informs you that she feels fine. You check her thyroid function tests and these show:

What is the most likely explanation for these results?

This woman with a diagnosis of hypothyroidism replaced with thyroxine has strange thyroid function tests with a slightly elevated T4 and a high TSH. The most likely explanation is poor compliance with her treatment. What typically happens is that the patient forgets medication causing the free T4 level to fall and hence the TSH rises. However, when the patient is due an appointment, they may double up on the dose and take more thyroxine, hence the Free T4 rises but it takes longer for the TSH to fall, hence these rather strange results. In this case it would be worth discussing compliance with the patient.

Non compliance with thyroxine case report:

http://www.medscape.com/viewarticle/410826_2

Question 8

A 75 year old male presents to the clinic because of tiredness. He is found to have the following thyroid function tests:

Which of the following is the most appropriate interpretation of these results?

This man has a normal T4 yet the TSH is low. This is called subclinical hyperthyroidism. The T4 is not above the normal range but is too high for this patient, as revealed by the suppressed TSH. This is often due to a small toxic adenoma of the thyroid gland which is beginning to release more T4 and so suppress the TSH (by negative feedback). Other possible causes include a multinodular goitre and Graves disease. Its worth also looking for secondary causes of low TSH with normal thyroid hormone levels, eg medications such as glucocorticoids, dopaminergic drugs or amiodarone. The condition should be treated as there is a greater risk of accelerated bone loss as well as atrial fibrillation if left untreated. Typically, treatment is with radio-iodine.

http://www.aafp.org/afp/2002/0201/p431.html

Question 9

A 45 year old woman attended clinic complaining that she has had problems with gradual weight gain and tiredness. Her weight has increased by approximately 10kg over the last couple of years. She has no family history of thyroid problems but is convinced that she has an underactive thyroid gland due to what she has read on the internet. There were no abnormalities to note on examination, other than a BMI of 30.5 kg/m

She now attends clinic wanting to know the results of the thyroid function tests.Which of the following actions is most appropriate?

This patient has normal thyroid function tests but has positive thyroid autoantibodies. The presence of thyroid autoantibodies suggest an increased chance of developing underactive thyroid at a rate of approximately 5% annually and so the majority would advocate annual thyroid function tests. Approximately 3% of the population may have elevated thyroid peroxidase antibodies yet be entirely normal. However, in general there is little point in measuring thyroid autoantibodies as a routine and it should only be performed in patients with overt or subclinical disease.

Diagnosis and Management of Common Thyroid Problems

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