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Hyperthyroid
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<<forEachTiddler where 'tiddler.tags.contains(context.inTiddler.title)' sortBy tiddler.title ascending write '"*[["+tiddler.title+"]]\n"'>> <<tiddler AutoRefresh with: force>> 2-3% F 0.2-0.3% M - Caucasians T4 / T3 - increases metabolic rate and sensitivity to sympathetic NS so causes .... weight loss heat intolerance, sweating tremor, palpitations (?AF) Irritable, poor concentration, sleep disturbance Diarrhoea Oligo / amenorrhoea Causes .... ''Graves (autoimmune)'' 70-90% - IgG to TSH receptor keeping it switched on - peaks 20-50yrs relapse and remit (wks to years) - esp if male, large goitre, more severe disease at presentation give initial Rx for over 1year - best chance for remission Abs present in 70% (antithyroid peroxidase (TPO) and anti-thyroglobulin (TG)) ''Toxic Adenoma'' - 3-5% - single follicular adenoma - solitary mobile neck lump ''Toxic Multinodular goitre'' - 15-20% - develops slowly, elderly, not resolve without surgery or I131 ''De Quervain's thyroiditis'' - ? response to acute viral illness, painful thyroid, Rx NSAID or steroid (30mg 2/52) takes 2-4/52 to resolve note ''thyrotoxicosis factitia'' (xs use thyroxine ?desire to loose weight) other rare causes - ''Pituitary adenoma, molar pregnancy, carcinoma'' ''Sx only with Graves'' Proptosis - enlarged extraocular muscles Thyroid dermopathy - esp pretibial - thickened skin with peau d'orange Thyroid acropachy - clubbing - soft tissue swelling and periosteal changes - fingers and toes ''Sx with all hyperthyroid'' eyelid retraction - overstimulation of Mullers muscle in eyelid AF - also with subclinical hyperthyroid - 15% - may need control thyroid, rate control AF and warfarin tremor - fine with hands outstretched - restlessness - helped with thyroid Rx and BB Also get ... hypercalcaemia normochromic normocytic anaemia abnormal LFT Some need Isotope scanning (functional test) but not all - 2ndary care request USS useful for nodules ''Medical Mx'' ''Carbimazole'' - can titrate dose to T4 level (risk hypothyroid) or block with high dose and replace with thyroxine (more SE, not good for fetus) takes - 2-3/52 to get response - recheck bloods 4-6/52 SE - headache, nausea, arthralgia, skin rash (change drug), agranulocytosis - rare but serious - sore throat, mouth ulcers, fever - stop drug if sore throat, usually recover in 1-2/52 - never give again ''Propylthiouracil'' - bd, more SE BB - help control Sx while thyroid drug works, then stop, not if asthma or heart failure ''Radioactive I131'' Destroys functioning follicular cells capsule or liquid - tasteless - stop antithyroid drugs week before and after giving I131 (so it can act) and need to be euthyroid pre I131 else risk thyroid storm half life 8 days, takes 6-8/52 to see effect, 60-80% resolve with one dose, can repeat at 4-6/12, no change in cancer risk with use avoid in pregnancy (not for 6/12 after I131) and if active thyroid eye disease, for 2-3/52 avoid kids and public transport (may trigger alarm at airport) - carry card to show recent admin TFT 3/12 for 1yr then annually - 80% Graves and 30% toxic adenoma will be hypothyroid by 20yrs after I131 inc risk of CVS disease and fracture (?hyper or hypothyroid or from Rx ??) ''Surgery'' Control medically first 98% cure rate with total / sub-total thyroidectomy indications - pt choice, medication untolerated, CI to I131, large goitre (cosmesis) 1% - haemorrhage, vocal cord paralysis, hypoparathyroidism hypothyroidism is expected AF - 5% in under 60 >20% in over 70 in sub-clinical hyperthyroidism too VTE risk is higher than AF alone - needs anticoagulation usually new hyperthyroid needs referral to 2ndary care for diagnosis and initial Mx after Ix bloods and imaging urgently if unwell, or to ophthalmology if severe eye Sx if starting meds in GP - discuss with hospital team
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Thyroid