A 44-year-old woman presents to her GP as she is feeling 'hot all the time' and is consequently worried she is going through an early menopause. Her husband has also noticed a 'fullness' of her neck which has become apparent over the past few weeks. On examination her pulse is 90/minute and she has a small, non-tender goitre.
Blood tests are arranged:
What is the most likely diagnosis?
Correct Answer E: The thyrotoxic symptoms and blood tests, goitre and anti-thyroid peroxidase antibodies suggest a diagnosis of Graves' disease.
The ESR result is within normal range.
Hashimoto's thyroiditis is associated with hypothyroidism.
Graves' disease: features: Graves' disease is the most common cause of thyrotoxicosis. It is typically seen in women aged 30- 50 years.
Features:
Features seen in Graves' but not in other causes of thyrotoxicosis:
Autoantibodies:
A 53-year-old female with a history of primary atrophic hypothyroidism is assessed two months following a change in her dose of levothyroxine.
Which one of the following best describes what the TSH should ideally be?
Correct Answer B: A TSH value between 0.5 to 2.5 mU/l is now considered preferable. Dosage changes should of course also take account of symptoms.
Hypothyroidism: management:
Key points:
Side-effects of thyroxine therapy:
Interactions:
A 69-year-old man who had a stroke 6 months ago is reviewed. After his diagnosis he was started on simvastatin 40mg on for secondary prevention of further cardiovascular disease. A fasting lipid profile taken one week ago is reported as follows:
According to recent NICE guidelines, what is the most appropriate action?
Correct Answer A: Nicotinic acid can raise HDL levels by up to 30% but in practice its use is limited by flushing. Any change to treatment should of course be in conjunction with continued lifestyle advice.
The increased risk of myopathy with the 80mg dose of simvastatin was recently highlighted by the Medicines and Healthcare products Regulatory Agency. Please see the link for more details.
Hyperlipidaemia: management:
In 2008 NICE issued guidelines on lipid modification. Key points are summarized below.
Primary prevention: A systematic strategy should be used to identify people aged 40-74 who are likely to be at high risk of cardiovascular disease (CVD), defined as a 10-year risk of 20% or greater. NICE updated their lipid guidelines so that the following risk models are valid:
The 1991 Framingham equations may still be used. It is however recommended that adjustments are made in the following situations:
Along with lifestyle changes drug treatment should be considered for patients with a 10-year CVD risk of 20% or greater:
Secondary prevention: All patients with CVD should be taking a statin in the absence of any contraindication NICE recommend increasing simvastatin to 80mg if a total cholesterol of less than 4 mmol/litre or an LDL cholesterol of less than 2 mmol/litre is not attained.
A 22-year-old female presents with recurrent painful oral ulceration. Examination reveals signs of oral Candidal infection.
Which one of the following would most suggest type 1 polyglandular syndrome?
Correct Answer A: Primary hypoparathyroidism is usually the first endocrine manifestation of type 1 autoimmune polyendocrinopathy syndrome. The contrast to multiple endocrine neoplasia (MEN), where hyperparathyroidism is a common finding, should be noted.
The question gives a slightly atypical history as this is the upper end of the age range in which patients would be expected to present.
Autoimmune polyendocrinopathy syndrome:
Addison's disease (autoimmune hypoadrenalism) is associated with other endocrine deficiencies in approximately 10% of patients. There are two distinct types of autoimmune polyendocrinopathy syndrome (APS), with type 2 (sometimes referred to as Schmidt's syndrome) being much more common.
APS type 2 has a polygenic inheritance and is linked to HLA DR3/DR4. Patients have Addison's disease plus either:
APS type 1 is occasionally referred to as Multiple Endocrine Deficiency Autoimmune Candidiasis (MEDAC). It is a very rare autosomal recessive disorder caused by mutation of AIRE1 gene on chromosome 21.
Features of APS type 1 (2 out of 3 needed):
Vitiligo can occur in both types.
A 23-year-old woman presents for review. She has not a normal period for around 8 months now. A recent pregnancy test was negative. Blood tests are ordered:
What is the most likely cause of her symptoms?
Correct Answer E: The bloods show a hypothalamic amenorrhoea which may be caused by stress or excessive exercise. The FSH would be raised in premature ovarian failure.
Amenorrhoea: Amenorrhoea may be divided into primary (failure to start menses by the age of 16 years) or secondary (cessation of established, regular menstruation for 6 months or longer).
Causes of primary amenorrhoea:
Causes of secondary amenorrhoea (after excluding pregnancy):
Initial investigations:
*Hypothyroidism may also cause amenorrhoea.
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