Fatima Patient medical history PMHx 34year old female Previously fit and healthy Symptoms Palpitations Sweating 10 kg weight loss in the last 2 months Irregular period in the last 2 months ID: 1044859
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1. Is Thyroid USS a must?Endocrine Society of Australia
2. FatimaPatient medical history (PMHx)34-year old female Previously fit and healthySymptomsPalpitationsSweating 10 kg weight loss in the last 2 monthsIrregular period in the last 2 months
3. Patient NameExaminationBP 106/70, HR 86/min, regularnil lid lag or ophthalmoplegia or proptosisdiffusely enlarged butterfly-shaped swelling in neck, moves with swallowing, non-tenderNil thyroid bruitmild fine tremorsnil clubbingAbsent Pemberton’s signbrisk reflexesnil proximal myopathynil pretibial myxedemaTests / Investigations TSH < 0.05 mIU/L (0.5-4.5)Free T4 33 pmol/L (7-18)Free T3 12 pmol/L (3.5-6)TSH receptor Ab 8.8 IU/L (<1.8)
4. What is the diagnosis?ThyroiditisToxic noduleGraves’ diseaseMultinodular goitre
5. QuestionThyroiditisToxic noduleGraves’ diseaseMultinodular goitre
6. Graves’ diseaseGraves’ disease should be suspected in patients presenting with signs and symptoms of thyrotoxicosis (tachycardia, weight loss or poor weight gain, and lid lag, often with tremor and neuropsychiatric symptoms)A significant share of these patients will have goitre and ophthalmopathy.The diagnosis of Graves disease as the cause of the thyrotoxicosis is confirmed by the presence of thyrotropin receptor antibodies (TSHR-Ab), which are detectable in the majority A positive thyroid-stimulating immunoglobulin (TSI) confirms the presence of a thyrotropin receptor (TSHR)-stimulating antibody.
7. Is Thyroid USS essential to diagnoseGraves’ disease?It is not essential if there is no asymmetrical or nodular enlargement on examinationAssessment with thyroid USS would significantly influence decision-making on management of thyroid nodules, but not for Graves’ diseaseAppropriate follow-up management plan is needed when thyroid nodules are detected
8. Choosing Wisely Australia RecommendationDon’t routinely order a thyroid ultrasound in patients with abnormal thyroid function testsif there is no nodular abnormality of thethyroid glandThe Endocrine Society of Australia
9. What is best practice?What are some common uses of thyroid ultrasound?An ultrasound of the thyroid is typically used:to analyse the appearance of thyroid nodules and determine if they are the more common benign nodule or if the nodule has features that require a biopsy. If biopsy is required, ultrasound guided needle aspiration can help improve accuracy of the biopsy.to look for additional nodules in patients with one or more nodules felt on physical examto see if a thyroid nodule has substantially grown over time
10. What is best practice?What are the limitations of thyroid ultrasound?Incidentally discovered thyroid nodules on ultrasound are common.Overzealous use of ultrasound will frequently identify nodules, which are unrelated to the abnormal thyroid function, and may divert the clinical evaluation to assess the nodules, rather than the thyroid dysfunction, which may lead to further unnecessary investigations, unwarranted patient anxiety and increased costs. Imaging may be needed in thyrotoxic patients; when needed, a radionuclide thyroid scan, not an ultrasound, is used to assess the etiology of the thyrotoxicosis and the possibility of focal autonomy in a thyroid nodule or nodules.
11. Referenceshttps://evolve.edu.au/recommendations/esahttps://www.radiologyinfo.org/en/info.cfm?pg=us-thyroidThyrotoxicosis and hyperthyroidism, Therapeutic Guidelines
12. How this case study was madeThis case study was developed by Dr Su Win Htike as a member or the RACP Evolve Policy Reference Group. This case study has been reviewed by the RACP Evolve Policy Reference Group in particular Prof Jane M Andrews, the Australian Diabetes Society, the Endocrine Surgery section of the Royal Australasian College of Surgeons, and NPS MedicineWise.This case study was approved for publication by the Endocrine Society of Australia Medical Affair Committee in August 2020.
13. Evaluation How likely is this Evolve recommendation to change your practice?Not at allSomewhatSignificantlyExplain your reasoning
14. choosingwisely.org.au