When to refer

• Doubt about the diagnosis

• Severe hyperthyroidism, especially if there is coexisting thyrocardiac disease

• Pregnant patients with hyperthyroidism

• Progression of exophthalmos

Thyroid carcinoma

The main presentations are a painless nodule, a hard nodule in an enlarged gland or lymphadenopathy with thyroid enlargement. Papillary carcinoma is the most common malignancy. Although rare compared with non-malignant lesions (such as colloid nodules, cysts, haemorrhage and benign adenomas), it is important not to miss carcinoma because of the very high cure rate with treatment. This involves total thyroidectomy, ablative I131 treatment, thyroxine replacement and follow-up with serum thyroglobulin measurements and thallium scanning. Fine needle aspiration is the investigation of choice.

Adrenal cortex disorders

It is worth keeping in mind the uncommon disorders of the adrenal cortex, which can also be difficult to diagnose in the early stages, namely:

• chronic adrenal insufficiency (Addison's disease)—deficiency of cortisol and aldosterone

• Cushing's syndrome—cortisol excess

• primary hyperaldosteronism (refer Chapter 111)

Addison's disease Clinical features

• lethargy/excessive fatigue

• anorexia and nausea

• diarrhoea/abdominal pain

• dizziness/funny turns o hypoglycaemia (rare) o postural hypotension (common)

• hyperpigmentation, especially mucous membranes of mouth and hard palate.

If Addison's disease remains undiagnosed, wasting leading to death may occur. Severe dehydration can be a feature.

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