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Hyperthyroidism - Coggle Diagram
Hyperthyroidism
Symptoms: Hyperthyroidism
Agitation, emotional lability, insomnia, irritability, anxiety, palpitations
Exercise intolerance, fatigue, muscle weakness
Compression symptoms of breathlessness, hoarse voice, dysphagia, neck pressure
Heat intolerance, increased sweating
Rapid-onset malaise, fever, and thyroid pain
Increased appetite with unintentional weight loss, diarrhoea
Reduced libido, gynaecomastia in men
Subfertility, oligomenorrhoea, amenorrhoea
Deterioration in blood glucose control and hyperglycaemia in people with diabetes mellitus.
Polyuria, thirst, generalized itch
Deterioration of co-morbid heart disease, for example in the elderly.
Signs: Hyperthyroidism
Splenomegaly, lymphadenopathy
Gynaecomastia in men
Muscle wasting, proximal myopathy, hyper-reflexia
Extrathyroid manifestations of Graves' disease (rare): Thyroid acropachy (clubbing and swelling of the distal fingers and toes), Thyroid dermopathy (slightly pigmented thickened skin and swelling of both legs, usually in the pretibial area)
Pruritus, urticaria, vitiligo, diffuse alopecia
Thyroid enlargement (a goitre)
Sinus tachycardia, atrial fibrillation, heart failure, peripheral oedema
Agitation, fine tremor, warm moist skin, palmar erythema
Risk factors
Low iodine
Autoimmune disease
Graves' disease
Smoking
Family history
Female sex
Graves' orbitopathy: Clinical features
Persistent double vision in any direction of gaze (typically when looking upwards and outwards).
Unexplained deterioration in visual acuity; change in the intensity or quality of colour vision in one or both eyes; orbital aching or restricted eye movements
Change in the appearance of the eye or eyelids: Eyelid retraction, Lid lag and Proptosis.
History of globe subluxation
Redness of the eyes or eyelids and/or lid swelling.
Eye irritation, photophobia, or excessive watering of the eyes.
Assessment: History
Any possible features of pituitary disease, such as history of brain or metastatic cancer, headache or visual field defects.
Any risk factors of hyperthyroidism.
Any drug treatment that may affect TFTS, including Levothyroxine medication or recent exposure to radioactive iodine contrast media.
Any current or recent non-thyroidal illness or other possible causes of a transiently suppressed thyroid-stimulating hormone (TSH) level.
Current or recent pregnancy
Ask about typical symptoms - severity, duration.
Investigations
Thyroid function tests
If the TSH level is below the normal reference range, the free thyroxine (FT4) and free triiodothyronine (FT3) levels should be measured in the same sample.
Other: TSH-receptor antibodies (TRAbs), ESR, CRP, Thyroid peroxidase antibodies (TPOAbs), FFBC, LFTs.
Suspect a diagnosis of overt hyperthyroidism if the TSH level is low and FT4 and/or FT3 levels are raised above the normal reference ranges.
Suspect a diagnosis of subclinical hyperthyroidism if the TSH level is below the normal reference range and FT3 and FT4 levels are within the normal reference range.
Arrange an ultrasound of the neck to image palpable thyroid enlargement or focal nodularity in adults with normal thyroid function if malignancy is suspected.
Management: Overt Hyperthyroidism
Consider seeking specialist advice about starting antithyroid drugs such as carbimazole in primary care for people: with symptoms despite treatment with a beta-blocker or beta-blocker is not tolerated/contraindicated, at risk of complications, or taking medication such as amiodarone or lithium.
While waiting specialist assessment: Consider prescribing a beta-blocker and titrating the dose depending on clinical response, to provide relief of adrenergic symptoms (such as palpitations, tremor, tachycardia, or anxiety).
Arrange referral or discuss with an endocrinologist the need for specialist investigations and management, for all other people with new-onset hyperthyroidism, the urgency depending on clinical judgement. In particular, if the person: goitre, nodule, structural change in the thyroid gland, if malignancy is suspected. Or is planning pregnancy.
Arrange urgent referral to an endocrinologist for specialist assessment if a pituitary or hypothalamic disorder is suspected, depending on clinical judgement.
Offer sources of information and support.
Arrange emergency admission if there are symptoms suggesting a serious complication.
Follow up
Seek specialist endocrinology advice or arrange referral to endocrinology, depending on clinical judgement, if: The free thyroxine (FT4) level falls below the reference range, or the thyroid-stimulating hormone (TSH) level is raised, as a dose reduction or drug withdrawal of antithyroid medication may be needed, FT4 is persistently raised 6 months after completion of radioactive iodine treatment, TSH level is greater than 20mU/L for more than one month.
If the person has untreated subclinical hyperthyroidism: Consider measuring the TSH level every six months. If the TSH level is outside the reference range, consider measuring free thyroxine (FT4) and free triiodothyronine (FT3) in the same sample. Consider stopping TSH monitoring if the TSH level stabilises.
If the person is taking propylthiouracil, advise them to: Seek urgent medical advice if they develop possible symptoms of liver disease, such as anorexia, nausea, vomiting, fatigue, abominal pain, jaundice, light-coloured stool, dark urine, or itch.
If the person is taking carbimazole, advise them to: Seek urgent medical advice if they develop possible symptoms of acute pancreatitis.
If the person is taking carbimazole or propylthiouracil, advise them to: Seek urgent medical advice if they develop possible symptoms of agranulocytosis or neutropenia such as fever, sore throat, mouth ulcers, febrile or non-specific illness, bruising, or malaise, and to stop the medication immediately.
Advise to attend for regular blood monitoring during and after antithyroid drug treatment, radioactive iodine treatment, or thyroid surgery, as per endocrinologist.
Examination
Signs of Graves' disease, including orbitopathy.
Signs of other autoimmune disease such as type 1 diabetes mellitus and vitiligo.
Thyroid enlargement (a goitre) and/or thyroid nodules, tenderness, and symmetry.
Possible signs or complications of hyperthyroidism, including assessment of pulse, blood pressure, temperature, weight, signs of fluid overload or heart failure.
Specialist Managment
Antithyroid drugs
Radioactive iodine treatment
Specialist investigations
Thyroid surgery
Management: Suspected Graves' orbitopathy
Provide sources of information and support.
Whilst awaiting specialist assessment, advise the person on: smoking cessation, use of artificial tears to lubricate the eyes, avoidance of irritation and damage to the eyes and elevating the head of the bed.
Arrange a routine referral to an ophthalmologist with a special interest in thyroid eye disease (or a joint endocrinology and thyroid eye clinic if available) for all other people.
Arrange emergency admission or seek immediate advice from an ophthalmologist with a special interest in thyroid eye disease, if a person has a suspected sight-threatening complication, such as: dysthyroid optic neuropathy, history of globe subluxtion or corneal exposure.
Managment: Subclinical Hyperthyroidism
Offer information and support.
Arrange referral to an endocrinologist for specialist investigations and management if: There are two thyroid-stimulating hormone (TSH) readings lower than 0.1 mU/L at least three months apart and There is evidence of thyroid disease (for example, a goitre or positive TSH-receptor antibodies) or symptoms of thyrotoxicosis.
Arrange an urgent referral using a suspected cancer pathway if: A person has a goitre, nodule, or structural change in the thyroid gland, if malignancy is suspected.
Definition: Hyperthyroidism is a biochemical diagnosis which occurs when there is pathologically increased thyroid hormone production and secretion by the thyroid gland. Thyrotoxicosis is the clinical manifestation of excess circulating thyroid hormones due to any cause, including hyperthyroidism. Primary hyperthyroidism occurs when thyrotoxicosis is caused by an abnormality of the thyroid gland. Thyrotoxicosis without hyperthyroidism describes thyrotoxicosis without thyroid gland overactivity, which is usually transient.