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Clinical aspects of thyroid disorders (2015)
1. CLINICAL ASPECTS
OF
THYROID DISORDERS
Alaa Wafa MD
Associate Professor of Internal Medicine
PGDIP DM Cardiff University UK
Diabetes & Endocrine Unit.
Mansoura University
( Sem 5 ) 2015
2. Janet ,,Case 5 Scenario
A 30-year-old woman
Nervousness, irritability, palpitations
and heat intolerance.
Lost 9.1 kg despite a good appetite.
Her eyes bulge.
Diffuse enlargement thyroid gland.
Carbimazole and propranolol are
prescribed.
6. Clinical Exam. of Thyroid
• Have patient seated on a chair
• Inspect neck before & after
swallowing
• Examine with neck in relaxed
position
• Palpate from behind the patient
• Remember the rule of finger tips
• Use the tips of fingers for
palpation
• Palpate firmly down to trachea
8. Goiter
• A swollen thyroid
gland
• Assessment;
– how big, how quickly
has it developed, is
it smooth or nodular,
is it painful, any
associated lymph
nodes, any sudden
changes, is it big
enough to cause
local symptoms (e.g.
breathing problems)
22. Hyperthyroidism Symptoms
Hyperactivity/ irritability
Heat intolerance and sweating
Palpitations
Fatigue and weakness
Weight loss with increase of appetite
Diarrhoea
Polyuria
Oligomenorrhoea, loss of libido
23. Hyperthyroidism Signs
Tachycardia (AF)
Tremor
Goiter
Warm moist skin
Proximal muscle
weakness
Lid retraction or
lag
Gynecomastia
24. Causes of Hyperthyroidism
Most common
causes
Graves disease
Toxic multinodular
goiter
Autonomously
functioning nodule
Rarer causes
Thyroiditis or other
causes of destruction
Thyrotoxicosis factitia
Iodine excess (Jod-
Basedow phenomenon)
Secondary causes (TSH
or ßHCG)
25. Graves Disease
Autoimmune disorder
Abs directed against TSH receptor
with intrinsic activity. Thyroid and
fibroblasts
Responsible for 60-80% of
Thyrotoxicosis
More common in women
26. Graves Disease Eye
Signs(Ophthamopathy)
N - no signs or symptoms
O – only signs (lid retraction
or lag) no symptoms
S – soft tissue involvement
(peri-orbital oedema)
P – proptosis (>22
mm)(Hertl’s test)
E – extra ocular muscle
involvement (diplopia)
C – corneal involvement
(keratitis)
S – sight loss (compression
of the optic nerve)
27. Ophthalmopathy
Signs of Graves’s ophthalmopathy are
divided into two components:
1) Spastic: Stare, lid lag and lid retraction
which account for the “frightened” facies.
2) Mechanical: Proptosis of varying
degrees,ophthalmoplegia,and congestive
occulopathy characterized by
chemosis,conjunctivitis,periorbital
swelling and the potential complications
of corneal ulceration,optic neiritis and
optic atrophy.
28.
29. Hyperthyroid Eye Disease
Hyperthyroidism (any cause)
Lid lag, lid retraction and stare
Due to increased adrenergic
tone stimulating the levator
palpebral muscles.
True Graves’ Ophthalmopathy
Proptosis
Diplopia
Inflammatory changes
• Conjunctival injection
• Periorbital edema
• Chemosis
Due to thyroid autoAb’s that
cross-react w/ Ag’s in
fibroblasts, adipo-cytes, +
myocytes behind the eyes.
41. Dermopathy
• Usually occurs over the dorsum of the legs or feet
and is termed localized or pretibial myxedema.
• It is usually a late phenomenon
• The affected area is usually demarcated from the
normal skin by being raised and thickened and
having a peau d’ orange appearance;it may be
pruritic and hyperpigmented.
• The most common presentation is non pitting
oedema,but lesions maybe plaque like,nodular or
polypoid.
• Clubbing of the fingers and toes accompanies and is
termed thyroid acropachy
58. Hyperthyroidism (Treatment)
1) β-blockers (symptom control)
Propranolol (Inderal ®)
2) 131-RAIA (70% thyroidologists prefer)
Dosing
• Graves: 10-15 mCi
• Toxic MNG/Adenoma: 20-30 mCi
Absolute contraindications
• Pregnancy and lactation (excreted in breast milk)!
Pregnancy should be deferred for at least 6 months
following therapy with radio-active 131
It is advisable to avoid 131-Rdio-active iodine therapy in
patients with active moderate severe Graves’
ophthalmopathy.
59. Hyperthyroidism (Treatment)
3) Antithyroid Drugs (30% thyroidologists prefer)
Propylthiouracil (PTU)
• 100 mg bid-tid to start
Methimazole
• 10X more potent the PTU
• 10 mg bid-tid to start
Complications of ATD’s
• Agranulocytosis (1/200-500)
• usually presents w/ acute pharyngitis/ tonsilitis or
pneumonia.
• Rash
• Hepatic necrosis, Cholestatic jaundice
• Arthralgia
60. Hyperthyroidism (Treatment)
4) Surgery (sub-total thyroidectomy)
Indications
• Patient preference
• Large or symptomatic goiters
• When there is question of malignancy
Need to be euthyroid prior to surgery
• To ↓ the risk of arrhythmias during induction of anesthesia
• To ↓ the risk of thyroid storm post operatively
• ATD’s + β-blockers
Risks
• Permanent hypoparathyroidism
• Recurrent laryngeal nerve problems
• Permanent hypothyroidism
70. Causes of Hypothyroidism
Autoimmune
hypothyroidism
(Hashimoto’s,
atrophic thyroiditis)
Iatrogenic
(I123treatment,
thyroidectomy,
external irradiation of
the neck)
Drugs: iodine excess,
lithium, antithyroid
drugs, etc
Iodine deficiency
Infiltrative disorders
of the thyroid:
amyloidosis,
sarcoidosis,
haemochromatosis,
scleroderma
71. Lab Investigations of
Hypothyroidism
TSH , free T4
Ultrasound of thyroid – little value
Thyroid scintigraphy – little value
Anti thyroid antibodies – anti-TPO
S-CK , s-Chol , s-Trigliseride
Normochromic or macrocytic anemia
ECG: Bradycardia with small QRS
complexes
72. Treatment of
Hypothyroidism
Levothyroxine
If no residual thyroid function 1.5 μg/kg/day
Patients under age 60, without cardiac
disease can be started on 50 – 100 μg/day.
Dose adjusted according to TSH levels
In elderly especially those with CAD the
starting dose should be much less (12.5 – 25
μg/day)
74. Thyroiditis
Acute: rare and due to suppurative
infection of the thyroid
Sub acute: also termed de
Quervains thyroiditis/
granulomatous thyroiditis – mostly
viral origin
Chronic thyroiditis: mostly
autoimmune (Hashimoto’s)
75. Thyroiditis
The most common form of
thyroiditis is Hashimoto thyroiditis,
this is also the most common cause
of long term hypothyroidism
The outcome of all other types of
thyroiditis is good with eventual
return to normal thyroid function