Hypothyroidism
Insufficient thyroid hormone production. Primary hypothyroidism (thyroid gland failure) is most common; secondary (pituitary failure) is rare. TSH is the single best first-line test.
Causes
Autoimmune
- Hashimoto's thyroiditis — most common worldwide; TPO antibodies positive; may have transient hyperthyroid phase
- Atrophic autoimmune thyroiditis
Iatrogenic
- Post-radioiodine (I-131) therapy
- Post-thyroidectomy (total)
- External beam radiotherapy to neck
Medications
- Amiodarone — high iodine content; causes hypo or hyperthyroidism
- Lithium — inhibits thyroid hormone release
- Interferon-alpha, tyrosine kinase inhibitors
Other Causes
- Iodine deficiency (dietary/geographic)
- Congenital — thyroid agenesis/dyshormonogenesis
- Infiltrative — sarcoidosis, amyloidosis
- Secondary/tertiary — pituitary/hypothalamic disease (TSH low or inappropriately normal)
Clinical Features
Symptoms (Slowing Down)
Fatigue & lethargy
Weight gain
Cold intolerance
Constipation
Dry skin
Hair loss / coarse hair
Bradycardia
Depression
Cognitive slowing
Menstrual irregularity
Hoarse voice
Periorbital puffiness
Signs
- Myxoedema — non-pitting oedema of skin; doughy texture; periorbital puffiness
- Goitre (Hashimoto's — firm rubbery)
- Slow-relaxing reflexes (delayed ankle jerk)
- Bradycardia, diastolic hypertension
- Carpal tunnel syndrome
- Hypercholesterolaemia, hyponatraemia
- Macrocytic anaemia (pernicious anaemia association)
- Pleural/pericardial effusion (severe)
Investigations
| Test | Result in Primary Hypothyroidism |
|---|---|
| TSH (first-line) | RAISED >4.0 mU/L |
| Free T4 | LOW <10 pmol/L |
| Free T3 | Low (may be normal early) |
| TPO antibodies | Positive in Hashimoto's (~95%) |
| Thyroglobulin Ab | Positive in Hashimoto's |
| Lipids | Raised LDL/total cholesterol |
| FBC | Macrocytic anaemia possible |
| Sodium | Hyponatraemia (SIADH-like) |
Key point: TSH alone is sufficient for screening and monitoring primary hypothyroidism. Free T4 added when TSH is abnormal or secondary hypothyroidism suspected.
Treatment: Levothyroxine
Starting Dose
- Adults <60 years, no cardiac disease: 1.6 mcg/kg/day (approx 50–100 mcg)
- Elderly / cardiac disease: start 25–50 mcg; titrate slowly every 6–8 weeks
- Children: higher weight-based dosing; endocrine specialist
Administration — Critical Points
- Take 30–60 minutes before food (empty stomach — best absorption)
- Swallow whole with plain water
- Consistent time each day (morning preferred)
Interactions — Separate by 4 Hours
PPI / antacids
Calcium supplements
Iron supplements
Cholestyramine
Sucralfate
Monitoring
- Recheck TSH 6–8 weeks after any dose change
- Target TSH: 0.4–4.0 mU/L (lower 0.4–2.0 in pregnancy)
- Annual TFTs once stable
Subclinical Hypothyroidism
Definition: TSH raised (4.0–10 mU/L) with normal free T4, often asymptomatic.
When to Treat
- TSH >10 mU/L — most guidelines recommend treatment
- TSH 4–10 with symptoms, positive TPO antibodies, or pregnancy
- Progression to overt hypothyroidism ~5% per year if TPO antibodies positive
If Not Treating
- Repeat TFTs in 3–6 months to confirm, then annually
- Cardiovascular risk — still unclear benefit of treating subclinical hypothyroidism in elderly
Congenital Hypothyroidism
Incidence: 1 in 3,000–4,000 neonates. Most common preventable cause of intellectual disability.
Neonatal Screening
- Heel-prick blood spot — TSH at day 5–7 (UK) or at birth (some programmes)
- GCC countries have established newborn screening programmes
- Raised TSH triggers urgent confirmation and treatment
Treatment
- Levothyroxine started within 2 weeks of birth — ideally within 1–2 weeks of screen result
- Goal: normalise T4 rapidly; maintain TSH 0.5–2.0 mU/L in infancy
- Regular monitoring; dose adjusted as child grows
Delayed treatment causes cretinism — irreversible cognitive impairment. Early treatment = normal development.
Hyperthyroidism
Excess thyroid hormone production. Presentation ranges from mild anxiety/palpitations to life-threatening thyroid storm. TSH is suppressed in all primary causes.
Causes
Graves' Disease (Most Common, ~75%)
- Autoimmune — TSH receptor antibodies (TRAb) stimulate thyroid
- Diffuse smooth goitre
- Exophthalmos (proptosis) — Graves ophthalmopathy; can be unilateral
- Pretibial myxoedema — non-pitting oedema of shins
- Thyroid acropachy (clubbing)
- Young to middle-aged women predominance
Toxic Multinodular Goitre (TMNG)
- Multiple autonomously functioning nodules
- Older patients; large goitre palpable
- TRAb negative
Solitary Toxic Adenoma (Plummer's Disease)
- Single hot nodule on isotope scan
- Remainder of thyroid suppressed
Thyroiditis Syndromes
- Subacute (De Quervain's) — viral; painful goitre; self-limiting; ESR raised; brief hyper then hypo phase
- Postpartum thyroiditis — 5–7% of women; autoimmune; hyper then hypo; usually resolves
- Amiodarone-induced — type 1 (iodine excess → TMNG/Graves) or type 2 (destructive thyroiditis)
- Silent painless thyroiditis
Clinical Features
Symptoms (Speeding Up)
Weight loss (with appetite)
Heat intolerance
Tremor (fine)
Palpitations
Atrial fibrillation
Diarrhoea
Anxiety / irritability
Sweating
Oligomenorrhoea
Muscle weakness (proximal)
Insomnia
Signs
- Tachycardia / AF (new AF warrants TFTs)
- Warm moist skin; palmar erythema
- Fine tremor (outstretched hands)
- Proximal myopathy (difficulty rising from chair)
- Onycholysis (nails lifting — Plummer's nails)
- Goitre (diffuse in Graves, nodular in TMNG)
- Thyroid bruit (Graves — increased vascularity)
Graves Eye Signs
- Lid lag (von Graefe's sign)
- Lid retraction — sclera visible above iris
- Proptosis / exophthalmos — measured by Hertel exophthalmometer
- Periorbital oedema, chemosis
- Diplopia — extraocular muscle involvement
- Corneal exposure — ulceration risk
Investigations
| Test | Result in Hyperthyroidism |
|---|---|
| TSH (first-line) | SUPPRESSED <0.1 mU/L |
| Free T4 | RAISED (overt) |
| Free T3 | RAISED (T3 toxicosis possible) |
| TRAb | Positive in Graves' (~98%) |
| TPO antibodies | Also positive in Graves' (lower specificity) |
| Thyroid USS | Goitre morphology, nodules |
| Isotope scan (Tc99m / I-123) | Diffuse uptake (Graves), hot nodule (adenoma), reduced uptake (thyroiditis) |
| ESR / CRP | Raised in De Quervain's |
Medical Treatment
Carbimazole (First-Line UK/GCC)
- Blocks thyroid peroxidase — inhibits hormone synthesis
- Initial dose 20–40 mg/day; titrate down as euthyroid achieved (6–8 weeks)
- Block and replace: carbimazole + levothyroxine together — stable control
- Titration regimen: dose adjusted by TFTs every 4–8 weeks
- Treatment course: typically 12–18 months; 50% remission rate in Graves
AGRANULOCYTOSIS WARNING: Occurs in ~0.3% of patients. Patient must be counselled to stop carbimazole immediately and seek urgent medical review if they develop sore throat, mouth ulcers, or fever. Check FBC urgently — neutropenia = stop drug.
Propylthiouracil (PTU)
- Also blocks T4→T3 conversion (useful in thyroid storm)
- Preferred in first trimester pregnancy (carbimazole teratogenic in T1)
- Use carbimazole in T2/T3
- Risk of hepatotoxicity — monitor LFTs
Beta-Blockers
- Propranolol 40 mg TDS — symptom control (tremor, palpitations, anxiety)
- Does not affect thyroid hormone levels
- Use while waiting for antithyroid drugs to take effect (4–8 weeks)
- Also inhibits T4→T3 conversion at high doses
Definitive Thyroid Treatment
Options: radioiodine (I-131), thyroid surgery, or continued long-term medical therapy. Choice depends on aetiology, patient preference, goitre size, Graves ophthalmopathy, and pregnancy status.
Radioiodine (I-131) Therapy
Mechanism
Oral capsule or liquid of radioactive iodine-131. Concentrated selectively by thyroid tissue → beta radiation destroys thyroid cells over weeks to months.
Indications
- Graves' disease (relapse after antithyroid drugs or patient preference)
- Toxic multinodular goitre
- Solitary toxic adenoma
- Post-thyroid cancer ablation
Radiation Precautions (3–5 days post-treatment)
Patient must be counselled:
- Avoid close contact with children under 16
- Avoid close contact with pregnant women
- Avoid public transport for first 3–5 days
- Sleep alone; use separate bathroom if possible
- Stay >1 metre from others for prolonged contact
- Avoid workplaces with children / pregnant colleagues for 1–2 weeks
- Flush toilet twice after use
Outcomes & Follow-up
- Hypothyroidism expected in 6–12 months (goal of treatment)
- Lifelong levothyroxine replacement required
- TFTs at 4–6 weeks, 3 months, 6 months, then annually
- May need repeat dose (~20% cases)
Contraindications
Pregnancy
Breastfeeding
Planning pregnancy <6 months
Graves Ophthalmopathy: Radioiodine may worsen eye disease. Consider prophylactic oral prednisolone cover. Active/severe eye disease may be a relative contraindication — discuss with ophthalmology.
Thyroidectomy
Types
- Total thyroidectomy: removes entire thyroid; requires lifelong levothyroxine
- Subtotal / near-total: leaves small remnant; may avoid levothyroxine but higher recurrence risk
- Hemithyroidectomy (lobectomy): one lobe removed; for solitary nodule/adenoma
Indications
- Large goitre with compressive symptoms (dysphagia, stridor)
- Thyroid nodule — suspicious/confirmed malignancy
- Patient preference (vs radioiodine/antithyroid drugs)
- Graves' in pregnancy if antithyroid drugs fail (2nd trimester)
- Antithyroid drug allergy/intolerance
- Retrosternal goitre
Post-Operative Nursing: Critical Complications
1. Hypocalcaemia (Hypoparathyroidism)
Parathyroid glands inadvertently removed or devascularised. Onset 12–72 hours post-op.
- Chvostek's sign: tap facial nerve anterior to ear → facial muscle twitch
- Trousseau's sign: inflate BP cuff above systolic for 3 min → carpal spasm
- Symptoms: perioral tingling, finger tingling, muscle cramps, tetany, seizures, laryngospasm
- Immediate treatment: IV calcium gluconate 10 mL of 10% over 10 min
- Maintenance: oral calcium + vitamin D (alfacalcidol)
2. Recurrent Laryngeal Nerve (RLN) Palsy
Injury during surgery → hoarse voice. Unilateral: hoarseness. Bilateral: stridor/airway emergency.
- Assess voice quality post-op (hoarseness)
- Bilateral damage — emergency: prepare for reintubation
- Intraoperative neuromonitoring used to reduce risk
3. Post-op Haematoma (Airway Emergency)
Expanding neck haematoma → tracheal compression → respiratory distress.
- URGENT: open wound at bedside (clip removers/suture scissors at bedside always)
- Call surgical team immediately
- Prepare for emergency reintubation/tracheotomy
- Onset: first 4–6 hours post-op most common
Thyroid Emergencies
Rare but life-threatening. Require immediate recognition, escalation, and ICU-level management. Mortality remains significant even with optimal treatment.
Thyroid Storm (Thyrotoxic Crisis)
Definition & Recognition
Extreme, life-threatening exacerbation of hyperthyroidism. Burch-Wartofsky scoring system used clinically.
Clinical Features
Fever >38.5°C (often >40°C)
Tachycardia / AF
Agitation / confusion
Vomiting / diarrhoea
Heart failure
Jaundice (hepatic failure)
Seizures / coma
Precipitants
- Surgery or trauma (especially untreated hyperthyroid patient)
- Infection / sepsis
- Iodinated contrast media
- Thyroid hormone overdose
- Withdrawal of antithyroid drugs
- Labour / delivery
- Radioiodine in inadequately prepared patient
Management — ICU Admission
A–E assessment. Call endocrinology & ICU immediately.
| Drug | Dose & Role |
|---|---|
| Propylthiouracil (PTU) | 600 mg loading, then 200 mg q4h — blocks synthesis + T4→T3 conversion (FIRST) |
| Lugol's iodine | Give 1 hr AFTER PTU — blocks hormone release (Wolff-Chaikoff) |
| Propranolol | IV/oral — controls tachycardia, blocks T4→T3 conversion |
| Hydrocortisone | 100 mg IV q8h — prevents relative adrenal insufficiency, blocks T4→T3 |
| Active cooling | Paracetamol + cooling blanket (NOT aspirin — displaces T4 from protein) |
| IV fluids | Fluid resuscitation; correct electrolytes |
| Treat precipitant | Antibiotics if infection, etc. |
Myxoedema Coma
Definition
Life-threatening decompensation of severe hypothyroidism. Misnomer — coma not always present.
Clinical Features
Hypothermia (core temp <35°C)
Bradycardia
Hypotension
Decreased consciousness
Hyponatraemia
Hypoglycaemia
Hypoventilation / CO2 retention
Myxoedematous facies
Precipitants
- Infection (most common)
- Cold exposure
- Sedative drugs (opioids, benzodiazepines)
- Surgery / trauma
- Non-adherence to levothyroxine
- Stroke / MI
Mortality 20–50% even with treatment. Early recognition and ICU admission are essential.
Management — ICU Admission
| Intervention | Details |
|---|---|
| IV Levothyroxine | 200–500 mcg IV loading, then 50–100 mcg IV daily |
| IV T3 (liothyronine) | 10–20 mcg IV then 10 mcg q4–8h — faster-acting; specialist guidance |
| IV Hydrocortisone | 100 mg q6–8h — empirical adrenal cover (before thyroid hormone) |
| Passive warming | Space blanket; avoid active warming (peripheral vasodilation → shock) |
| IV fluids | Cautious — risk pulmonary oedema; correct hyponatraemia slowly |
| Glucose | Dextrose if hypoglycaemic |
| Ventilation | Intubation if respiratory failure / GCS falling |
| Treat precipitant | Broad-spectrum antibiotics empirically (infection most common cause) |
Give hydrocortisone BEFORE levothyroxine to prevent precipitating adrenal crisis — relative adrenal insufficiency common in myxoedema coma.
Graves Ophthalmopathy (Thyroid Eye Disease)
Pathophysiology
Autoimmune inflammation of orbital fibroblasts, fat, and extraocular muscles. Driven by TRAb cross-reacting with orbital antigens. Can occur independent of thyroid status.
Clinical Activity Score (CAS)
Score 1 point each: spontaneous retrobulbar pain, pain on eye movement, eyelid erythema, conjunctival injection, chemosis, caruncle/plica inflammation, eyelid oedema.
CAS ≥3/7 = active disease → likely to respond to immunosuppression.
Classification (EUGOGO)
- Mild: minor soft tissue signs, <2 mm proptosis change, no corneal involvement, no diplopia
- Moderate-severe: significant soft tissue, ≥3 mm proptosis, inconstant/constant diplopia
- Sight-threatening: dysthyroid optic neuropathy (DON) or corneal breakdown — EMERGENCY
Management
| Severity | Treatment |
|---|---|
| Mild | Euthyroidism, lubricant eye drops, sunglasses, selenium supplementation |
| Moderate-Severe (active) | IV methylprednisolone pulsed — 500 mg IV weekly × 6 weeks, then 250 mg × 6 weeks |
| Inactive disease | Rehabilitative surgery (orbital decompression, strabismus, lid surgery) |
| Sight-threatening DON | High-dose IV methylprednisolone → if no improvement within 1–2 weeks → urgent orbital decompression |
Nursing Care Points
- Corneal protection: lubricating eye drops QID, ointment at night
- Tape eyelids closed at night if exposure risk
- Elevate head of bed — reduces periorbital oedema
- Dark glasses for photophobia
- Monitor visual acuity and colour vision (optic nerve)
- Smoking cessation — strongly associated with worsening ophthalmopathy
Thyroid Cancer
Incidence rising globally, partly due to increased detection. Most thyroid cancers have excellent prognosis. Management involves multidisciplinary team: endocrinology, surgery, nuclear medicine, oncology.
Cancer Types & Characteristics
| Type | % of Cases | Origin | Key Features | Prognosis |
|---|---|---|---|---|
| Papillary | ~75% | Follicular cells | Psammoma bodies; Orphan Annie nuclei; lymph node spread common; RET/PTC rearrangement; BRAF mutation | Excellent — 10yr survival >95% |
| Follicular | ~15% | Follicular cells | Haematogenous spread (bone, lung); vascular/capsular invasion; RAS mutation; FNA cannot distinguish from adenoma | Good — 10yr survival ~85% |
| Medullary | ~5% | Parafollicular C cells | Calcitonin marker; 25% hereditary (MEN2/FMTC); RET proto-oncogene mutation; amyloid deposits; CEA raised | Moderate — 10yr survival ~75% |
| Anaplastic | <2% | Follicular cells (dedifferentiated) | Elderly patients; rapidly growing hard mass; locally invasive; no iodine uptake; TP53 mutation | Very poor — median survival <6 months |
| Lymphoma | <2% | Lymphocytes | Associated with Hashimoto's; often DLBCL; responds to chemo/radiotherapy | Variable |
Thyroid Nodule Investigation
Initial Assessment
- History: symptoms, risk factors (radiation, family history, MEN)
- Examination: size, consistency, fixation, lymphadenopathy
- TFTs: if TSH low → isotope scan first (functioning nodule rarely malignant)
- TSH normal/raised → proceed to USS
Thyroid Ultrasound — TIRADS Classification
Thyroid Imaging Reporting and Data System (ACR TIRADS / BTA U-grades):
| Grade | Features | Malignancy Risk |
|---|---|---|
| U1 / TR1 | Normal | None |
| U2 / TR2 | Benign (cystic, colloid) | <2% |
| U3 / TR3 | Indeterminate (follicular) | ~5% |
| U4 / TR4 | Suspicious (hypoechoic, irregular margins) | 5–80% |
| U5 / TR5 | Malignant (microcalcifications, taller than wide) | >70% |
Fine Needle Aspiration (FNA) — Bethesda System
| Bethesda | Category | Malignancy Risk | Action |
|---|---|---|---|
| I | Non-diagnostic | Inconclusive | Repeat FNA |
| II | Benign | <3% | Follow-up USS |
| III | AUS / FLUS | ~15% | Repeat / molecular testing |
| IV | FN/Suspicious for FN | ~25% | Lobectomy |
| V | Suspicious malignancy | ~75% | Total thyroidectomy |
| VI | Malignant | >97% | Total thyroidectomy |
Treatment of Differentiated Thyroid Cancer
Surgery
- Total thyroidectomy — primary treatment for papillary/follicular cancer >1 cm
- Central neck dissection — for lymph node involvement
- Lobectomy may be adequate for low-risk papillary microcarcinoma (<1 cm)
Radioiodine (I-131) Ablation
- Destroys remaining thyroid tissue + micrometastases
- Patient must be hypothyroid (TSH >30 mU/L) before administration — allows maximum iodine uptake
- Low-iodine diet 2 weeks before treatment
- Same radiation precautions as for hyperthyroidism therapy
- Post-ablation scan identifies residual/metastatic disease
TSH Suppression Therapy
- Levothyroxine at suppressive doses — target TSH <0.1 mU/L for high-risk disease
- Reduces TSH-driven tumour growth
- Risks: AF, osteoporosis with long-term suppression
- Target adjusted to risk: low-risk → TSH 0.5–2.0 mU/L after 5 years remission
Surveillance
- Thyroglobulin (Tg) — tumour marker for papillary/follicular cancer; rising Tg suggests recurrence
- Anti-thyroglobulin antibodies (interfere with Tg assay — measure both)
- Neck USS at 6–12 months, then annually
- Stimulated Tg (after rhTSH or thyroid hormone withdrawal) at 6–12 months
MEN2 & Medullary Thyroid Cancer
Multiple Endocrine Neoplasia Type 2
- MEN2A: medullary thyroid cancer + phaeochromocytoma + primary hyperparathyroidism
- MEN2B: MTC + phaeochromocytoma + marfanoid habitus + mucosal neuromas
- FMTC: familial MTC only
RET Mutation Screening
- All medullary thyroid cancer patients → RET germline testing
- First-degree relatives of RET carriers → cascade testing
- Annual calcitonin surveillance in carriers
- Prophylactic thyroidectomy in RET carriers — age determined by mutation codon risk
- Screen for phaeochromocytoma (24h urine catecholamines / plasma metanephrines) before thyroid surgery
GCC Context & Regional Considerations
GCC-Specific Thyroid Issues
Iodine Deficiency — Historical Context
- Historically significant in inland GCC areas (UAE, Saudi Arabia, Oman inland) — no coastal seafood access
- National iodination of salt programmes now widespread across GCC
- Surveillance: WHO/UNICEF joint monitoring; urine iodine concentration targets
- Risk remains in specific populations: pregnant women, rural communities
Graves Disease
- Prevalence similar to global rates in GCC
- Higher rates among women of childbearing age — particularly relevant for postpartum thyroiditis screening
Amiodarone-Induced Thyroid Disease
- High burden of cardiovascular disease in GCC → widespread amiodarone use
- Amiodarone contains ~37% iodine by weight
- Type 1 AIT: excess iodine triggers hyperthyroidism in underlying nodular disease — treat with carbimazole
- Type 2 AIT: destructive thyroiditis (no underlying disease) — treat with prednisolone
- Can also cause hypothyroidism
- Monitor TFTs every 6 months in ALL patients on amiodarone
Thyroid Cancer in GCC
- Rising incidence — particularly in UAE and Qatar
- Attributed to: increased healthcare access, improved detection with USS, high-resolution imaging
- Papillary microcarcinoma overdetection a recognised concern
- DHA-licensed thyroid cancer surveillance centres in Dubai
- Specialized thyroid cancer MDT in SEHA/HMC/MOH institutions
Ramadan Considerations
Levothyroxine Adherence During Ramadan
The standard instruction to take levothyroxine 30–60 min before food on an empty stomach is challenging during Ramadan fasting.
Recommended Strategy
- Take levothyroxine at Suhoor (pre-dawn meal) — ideally 30–60 min before eating, with water only
- Alternatively: take at Iftar — at least 30–60 min before the evening meal
- Some patients may take it at bedtime (2h after last meal) — bioavailability may be slightly higher
- Counsel that missing doses or irregular timing leads to TSH fluctuation and symptoms
- Recheck TFTs 4–6 weeks after Ramadan if adherence was disrupted
Postpartum Thyroiditis in GCC Women
- Affects ~5–7% of postpartum women; higher in those with TPO antibodies
- Often underdiagnosed — fatigue/mood changes attributed to postnatal period
- Screen women with previous postpartum thyroiditis, T1DM, or TPO antibodies at 3 months postpartum
- Biphasic: hyperthyroid 1–4 months → hypothyroid 4–8 months → recovery by 12 months in most
Regulatory & Licensing Context
- DHA (Dubai Health Authority) — endocrine nursing standards for Dubai
- DOH (Department of Health Abu Dhabi) — Abu Dhabi licensing and clinical standards
- MOH (Ministry of Health UAE) — federal standards
- SCFHS (Saudi Commission for Health Specialties) — Saudi licensing board
- QCHP (Qatar Council for Healthcare Practitioners) — Qatar licensing
DHA / DOH / SCFHS Exam Preparation
TSH Interpretation
| TSH | Free T4 | Interpretation |
|---|---|---|
| >10 | Low | Overt primary hypothyroidism |
| 4–10 | Normal | Subclinical hypothyroidism |
| 0.4–4 | Normal | Euthyroid (normal) |
| 0.1–0.4 | Normal | Subclinical hyperthyroidism |
| <0.1 | High | Overt hyperthyroidism |
| Low | Low | Secondary hypothyroidism (pituitary) |
Key Exam Scenarios
Carbimazole Agranulocytosis
Q: Patient on carbimazole develops sore throat and fever — next step?
A: STOP carbimazole. Urgent FBC. Medical review.
Q: Patient on carbimazole develops sore throat and fever — next step?
A: STOP carbimazole. Urgent FBC. Medical review.
Post-thyroidectomy Hypocalcaemia
Q: Patient develops perioral tingling and carpopedal spasm 24h post total thyroidectomy — diagnosis and treatment?
A: Hypoparathyroidism → hypocalcaemia. IV calcium gluconate 10%.
Q: Patient develops perioral tingling and carpopedal spasm 24h post total thyroidectomy — diagnosis and treatment?
A: Hypoparathyroidism → hypocalcaemia. IV calcium gluconate 10%.
Thyroid Storm
Q: Hyperthyroid patient develops fever, tachycardia, confusion after infection — management priority?
A: A-E assessment, PTU, Lugol's iodine (1h after PTU), propranolol, hydrocortisone, ICU.
Q: Hyperthyroid patient develops fever, tachycardia, confusion after infection — management priority?
A: A-E assessment, PTU, Lugol's iodine (1h after PTU), propranolol, hydrocortisone, ICU.
Must-Know Facts
- Levothyroxine: take 30–60 min before food
- TSH target on levothyroxine: 0.4–4.0 mU/L
- Carbimazole: agranulocytosis — stop if sore throat/fever → urgent FBC
- PTU preferred in first trimester pregnancy
- Radioiodine: avoid contact with children/pregnant women for 3–5 days
- Post-thyroidectomy: monitor for hypocalcaemia (Chvostek/Trousseau)
- Thyroid storm: PTU before Lugol's iodine
- Myxoedema coma: hydrocortisone before levothyroxine
- Papillary cancer marker: thyroglobulin
- Medullary cancer marker: calcitonin (+ CEA)
- MEN2: RET mutation testing; prophylactic thyroidectomy
- Neonatal screening: TSH on heel prick (congenital hypothyroidism)
- Graves ophthalmopathy: smoking worsens eye disease
- Aspirin contraindicated in thyroid storm — displaces T4 from binding protein
SCFHS Endocrine Nursing Exam Topics
Commonly Tested Areas
- TFT interpretation (TSH/T4/T3 patterns)
- Mechanism of action: levothyroxine, carbimazole, PTU, propranolol
- Drug interactions with levothyroxine
- Patient education: levothyroxine administration, Ramadan
- Carbimazole safety: agranulocytosis recognition and action
- Post-thyroidectomy complications: hypocalcaemia, RLN palsy, haematoma
- Radiation safety post-radioiodine
- Thyroid storm: recognition, priority management steps
- Myxoedema coma: recognition, treatment order
- Thyroid nodule: assessment pathway (USS → FNA)
- Thyroid cancer types and markers (Tg, calcitonin)
- Neonatal thyroid screening
- MEN2 / RET mutation significance
Clinical Decision Framework
When to refer urgently:
- Suspected thyroid storm → ED + endocrinology + ICU
- Decreased consciousness in hypothyroid patient → myxoedema coma protocol
- Post-thyroidectomy stridor → haematoma / RLN → surgical emergency
- Post-thyroidectomy tetany → IV calcium gluconate
- Carbimazole + sore throat/fever → stop drug, urgent FBC, haematology
- Rapidly enlarging thyroid mass → possible anaplastic cancer → urgent surgical review
- New AF in hyperthyroid patient → rate control + cardiology review
Exam tip — Priority Questions:
For management/priority questions, always select the option that ensures patient safety first (stop offending drug, secure airway, call for help) before investigations or treatments.