Pathology EMQ template.
Name: Jack Roberts
Theme: Thyroid
OPTION LIST
|
A |
Carbimazole |
I |
Potassium iodide |
|
B |
Chest Radiograph |
J |
Propranolol |
|
C |
Drug overdose |
K |
Radioiodine (131I) |
|
D |
Glucocorticoids |
L |
Reassess dose |
|
E |
Levothyroxine sodium |
M |
Sodium valproate |
|
F |
Liothyronine sodium |
N |
Supportive/watch and wait |
|
G |
Lithium carbonate |
O |
|
|
H |
Partial thyroidectomy |
P |
|
For each scenario below, choose the most appropriate answer from the list above. Each option may be used once, more than once or not at all.
1. A 40 year old woman presents to your GP surgery with painful, swollen finger joints. On examination you notice a ‘butterfly’ rash over her cheeks. She also complains of tiredness and constipation, and has recently been feeling ‘down and out’.
2. You are asked to review a patient that has been referred from the antenatal clinic. She complains of muscle cramps, restlessness, heat intolerance, and increased sweating. On further investigation she is found to have high T4/T3 levels, decreased serum TSH, and a toxic nodular goitre. What management do you recommend?
3. A female of 28 years presents to the psychiatric ‘crisis resolution team’ for assessment. Her speech is pressured, she appears to have flight of ideas, and varies from being happy to tearful in a matter of seconds. You start her on a number of drugs and review her some time later. She is well but now complains of deepening voice, weight gain and cold intolerance. What is the likely cause?
4. A 55 year old female presents to A&E with diarrhoea, weight loss, palpitations, and recent bilateral leg swelling. She deteriorates but is successfully stabilised. As the endocrinologist on call, you have a number of differentials based on the bloods and need to investigate with a further study.
5. Gary, a 66 year old post-gender reassignment surgery patient, returns for his outpatient appointment. He complains of painful dysphagia, fevers, tremor, and palpations. On examination he has a tender, enlarged thyroid gland. Bloods reveal elevated T4/T3, low TSH, and a raised ESR.
ANSWERS
|
1. E |
2. H |
3. G |
4. K |
5. J |
Notes:
1. Patient has primary hypothyroidism (autoimmune), more common alongside conditions such as SLE. E= Drug of choice. Liothyronine sodium (T3) has more rapid onset, used in myxoedema coma (rare), i.v.
2. Patient is pregnant and has Plummer’s disease. Radioiodine (131I) and carbimazole not wise (radiation and crosses placenta)
3. Hypothyroidism is a potential side effect of lithium (used in bipolar disorder). Watch thyroid function.
4. In lower doses, radioiodine can be used in thyroid scans (or 99-Tc pertechnetate). Determine cause of hyperthyroidism.
5. Gary has viral ‘de Quervain’ thyroiditis. Temporary beta blockade would be useful in symptom management. May progress to hypo before complete resolution. Antithyroid drugs are of no value because the excess T4 and T3 results from release of preexisting thyroid hormone by follicular damage rather than from active synthesis.