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Clin Med3: Endocrine > disorders of the thyroid - waldron > Flashcards

disorders of the thyroid - waldron Flashcards

1
Q

what is the largest endocrine organ in the body

A

thyroid

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2
Q

what hormones does the thyroid produce

A

calcitonin
thyroxine (T4)
tri-iodothyronine (T3)

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3
Q

what makes up the thyroid

A

follicular cells

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4
Q

how is the thryoid hormone regulated

A

negative feedback loop
high TSH - is a slow thyroid
low TSH - fast thyroid

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5
Q

what is Goiter

A

an enlarged thyroid or abnormal growth of thyroid gland
depending on cause: may be associated with normal, decreased or increased thyroid hormone production

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6
Q

what is the most common causes of Goiter

A

worldwide: iodine deficiency
US: multi-nodular goiter, chronic autoimmune thyroiditis (Hashimoto’s), Graves disease
physiological (puberty/pregnancy), dysmorphogenesis (sporadic), radiation exposure, TSH release from pituitary gland, autoimmunity, infection, granulomatous disease

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7
Q

what types of food may affect thyroid function

A

broccoli, kale, cauliflower, peaches, strawberries, mustard, teas, red wine, soy products

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8
Q

what synthesizes the thyroid hormone

A

iodine

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9
Q

what is sporadic goiter

A

dysmorphogenesis and endemic goiter (iodine deficiency) mostly occur during childhood; thyroid gland increases more in size with age

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10
Q

what is the presentation of Goiter

A

most asymptomatic
swelling may be discovered incidentally
concern for compressive symptoms: dysphagia, dyspnea, hoarseness
may compress neck veins causing facial congestion, discomfort
pain is rare

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11
Q

what is seen on PE with Goiter

A

central neck swelling
cervical LA think malignancy: workup accordingly
vocal cord exam if hoarseness or before surgical intervention
pemberton maneuver

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12
Q

what is Pemberton maneuver

A

elevating arms may lift goiter into thoracic inlet and cause stridor, dyspnea or enlargement of neck veins

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13
Q

how do you workup/diagnose Goiter

A

TSH, free T4, T3
US to assess nodules - FNA cytology under US guidance
CXR
CT/MRI
radionuclide scanning

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14
Q

If a TSH below normal when Goiter is suspected what needs to be assessed next

A

check serum free T4 and T3
- hyperthyroidism: graves disease, multinodular goiter, toxic adenoma

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15
Q

if a TSH is above normal when Goiter is suspected what needs to be assessed next

A

check T3 and T4
hypothyroidism: hashimoto’s thyroiditis most likely, ecept areas of endemic goiter due to iodine deficiency

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16
Q

what is the usual TSH range

A

0.45 - 4.5

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17
Q

What is the treatment of non-toxic goiter

A

no tx: annual follow up
medical therapy is controversial
if intervention: usually surgery (thyroidectomy = mainstay tx)
radioiodine ablations

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18
Q

what is the etiology of hypothyroidism

A

autoimmune thyroiditis
previous thyroid surgery
radiation therapy
lithium
PTU

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19
Q

what is the etiology of hyperthyroidism

A

Grave’s disease
toxic nodule (toxic adenoma)
toxic multi-nodular goiter (Plummer’s disease)
thyroiditis
silent, post-partum, deQuervains thryoiditis (subacute)

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20
Q

what is the presentation of hypothyroidism

A

anorexia
fatigue, depression, lethargy
cold intolerance
constipation
dry, coarse hair
anemia
muscle stiffness and or cramps
memory impairment
bradycarida
hypo-reflexia
(slows them down)

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21
Q

what is the presentation of hyperthyroidism

A

nervousness
heat intolerance
sweating
increased appetite, weight loss (some gain)
loose stools
irritability/anxiety
fatigue
muscle weakness
tachycardia, afib, palpitations, PACs
hyper-reflexia
(speeds them up)

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22
Q

What is graves disease

A

most common cause of hyperthyroidism
autoimmune disease: usu +FHx, F>M, associated with HLA
precipitated by environmental factors: stress, smoking, infection, iodine, exposure, post-partum
TSH-receptor antibodies (TRAb) stimulate thyroid hormone production

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23
Q

what causes graves disease

A

thyroid stimulating immunoglobulin (TSI)

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24
Q

what stimulates TSH

A

TRab binding with TSH receptor on the thyroid

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25
what causes hyperthyroidism and thyromegaly
TRab stimulating both thyroid hormone synthesis and thyroid gland growth
26
What is the process of Graves (toxic goiter, thyrotoxicosis)
stimulating antibodies to TSH-R (TRab) -> diffuse enlargement of thyroid gland -> increasing levels of thyroid hormones suppress TSH at anterior pituitary -> low TSH, normal or high T3, T4
27
What is the presentation of Graves disease
most patients present with signs and symptoms of hyperthyroidism rare presentation of graves orbitopathy (TED) depends on age of onset, severity, duration
28
how do the elderly present with graves disease
symptoms may be subtle/masked may have non-specific: fatigue, weight loss, new onset Afib atypical: "apathetic thyrotoxicosis"
29
what is the presentation of younger patients with graves disease
common presentation: heat intolerance, sweating, fatigue, weight loss, palpitation, hyperdefecation, tremors other possible: insomnia, anxiety, hyperkinesia, dyspnea, muscle weakness, pruritus, polyuria, loss of labido eyes: lid swelling, ocular pain, conjunctival redness, dipolopia
30
what are physical signs of hyperthryoidism
tachycardia, HTN with increased PP, signs of heart failure, afib, fine tremors, hyperkinesia, hyperreflexia, warm/moist skin, palmar erythema, hair loss, diffuse palpable goiter, AMS
31
what are the extrathyroidal manifestation signs
thyroid eye disease marked thickening of skin, mainly over tibia bone: sub-periosteal bone formation and swelling in metacarpal bones onchyolysis (plummer nails), clubbing: rare
32
what is thyroid storm
sudden on set with severe symptoms of thyrotoxicosis medical emergency - high mortality rate d/t cardiac arrhythmias HTN, tachy, fever, mental status changes, N/V/D
33
what is graves ophthalmopathy
proptosis, conjunctival irritation, eye pain, eye dryness, double vision -> refer to ophtho
34
how do you diagnose/work up graves disease
most pts: usually clear signs/symptoms diagnostic tests: TSI, TSH (low), T3 and T4 (elevated), TRab (elevated), tyroid radioavtive iodine uptake (i131), US to assess thyroid BF, CT/MRI of orbits
35
what is the treatment of hyperthyroidism
consider endocrine referral (strongly) medications: propylthiouracil (PTU), methimazole -radioactive iodine (RAI) tx -total thyroidectomy propranolol PO -supportive until thyrotoxicosis is resolved
36
what is the recommended first line treatment for graves disease
radioactive iodine advantages: permanent resolution, non-invasive disadvantages: results in hypothyroidism, delay of onset (6-8weeks)
37
when is radioactive iodine contraindicated
pregnant or breast-feeding women
38
what is the advantages/disadvantages of thiourea drugs (propylthiouracil (PTU) or methimazole)
weeks to control hyperthryoidism, usu. 12-24 months advantages: if spontaneous resolution, now euthyroid on no meds dis: difficult to control thyroid hormone levels, neurotpenia, liver enzyme elevation, rash, arthralgia, possibility of relapse
39
what is the drug of choice for graves disease with pregnancy
PTU (propylthiouracil)
40
what are the advantages/disadvantages with total thryoidectomy
advant: fast resolution of hyperthyroidism dis: invasive, full anesthesia, post-op hypothyroid consider in pregnant women intolerant to PTU
41
what is the treatment of thyroid storm
referral to endocrine via ER block thyroid hormone action: beta blocker block thyroid hormone release and conversion from T4 to T3: - PTU, postassium iodine, ipodate sodium (iodinated contrast), hydrocortisone IV supportive
42
What is Plummers disease
toxic nodular goiter (TNG) autonomously functioning thyroid nodules, with resulting hyperthyroidism second most common cause of hyperthyroidism in western world
43
What is the pathophysiology of TNG
spectrum of single hyperfunctioning nodule (toxic adenoma) within a multinodular thyroid to a gland with multiple areas of hyperfunctioning hyperthyroidism usu. occurs with single nodules > 2.5cm in diameter
44
What is the Jod-Basedow effect
initial iodine supplementation can lead to hyperthyroidism
45
What is the epidemiology for TNG
W>M women and men >40, prevalence rate of palpable nodule is 5-7% and 1-2% most patients with TNG > 50yo toxicity usu. peaks in 6th and 7th decade of life
46
what are the TNG thyrotoxic symptoms
signs of hyperthyroidism: heat intolerance, palpitations, tremor, weight loss, hunger, hyperdefication (usu. younger patients)
47
what are the symptoms for elderly patients with TNG
weight loss: m/c complain in elderly anorexia and constipation dyspnea or palpitations tremor: may be confused with essential tremor CV concerns: Hx AFib, HF, angina
48
what are obstructive symptoms of TNG
sx related to mechanical obstruction large substernal goiter: dysphagia, dyspnea, or frank stridor - rarely a sx emergency involvement of recurrent or superior laryngeal nerve may result in complains of hoarseness or voice change
49
what are the common lab findings with TNG
low TSH with NORMAL free T4
50
what is seen on PE with TNG
more subtle than graves widended, palpebral fissues; tachycardia; hyperkinesis; moist, smooth skin; tremor; proximal muscle weakness; brisk DTR
51
what is a positive Pemberton sign
mechanical obstruction may cause SVC syndrome
52
what is the diagnosis/work up for TNG
thryoid function test TSH: best initial screening tool; will be low free T4: elevated or normal nuclear scintigraphy (radioactive iodine - 123 - preferred) US or CT neck FNA
53
what is seen on nuclear scintigraphy with TNG
patchy with areas of increased and decreased uptake
54
what is the diagnosis/work up for TNG
thyroid function test TSH: best initial screening tool; will be low free T4: elevated or normal nuclear scintigraphy (radioactive iodine - 123 - preferred)
55
when is FNA indicated for TNG
autonomously functioning (hot) thyroid nodule dominant cold nodule present in mutinodular goiter clinically significant nodule >1cm max diameter non-palpable nodules; FNA with US assistance
56
what is the treatment for TNG
optimal tx remains contraversial autonomously functioning nodules should be treated definitively with radioactive iodine or surgery monitor meds/surgery endocrinology consult*
57
what are medication treatment options for TNg
anti-thyroid drugs (thioamides - PTU, methimazole) and beta blockers used for short courses
58
what is included within thyroiditis
spectrum of diseases: asymptomatic, hypothyroidism, with or without diffuse goiter, atrophic, occasionally painful, occasionally nodular, silent thyroiditis, postpartum thyroditis, thyrotoxicosis (rare)
59
What is Hashimoto's thyroiditis
autoimmune dx that destroys thyroid cells by cell and antibody-mediated immune process aka chronic autoimmune thyroiditis and chronic lymphocytic thyroditis formation of anti-thyroid antibodies that attack thyroid tissue causing progressive fibrosis
60
what is the m/c lab findings with hashimotos thyroiditis
elevated TSH, low free thyroxine (T4), increased anti-thyroid peroxidase (TPO) antibodies
61
what is the most common cause of hypothyroidism in iodine -suffieicne world (after age 6)
hashimotos thyroiditis
62
what is the conventional treatment of Hashimotos
levothyroxine at 1.6-1.8 mcg/kg/day
63
what is the patho of hashimotos thyroiditis
autoimmune origin with lymphocyte infiltration and fibrosis current dx based on clinical symptoms with lab results of elevated TSH and normal to low T4
64
what is the presentation of hashimotos
initially hyperthryoid sx skin: myxedma (dry and brittle hair and skin) cardiac: increased PVR, bradycardia, most present with pre-existing CV conditions fatigue, exertional dyspnea, exercise intolerance muscle weakness and myopathy
65
what are the early symptoms of Hashimotos
constipation, fatigue, dry skin, weight gain
66
what are teh advanced symptoms of hashimotos
cold intolerance, decreased sweating, nerve deafness, peripheral neuropathy, decreased energy, depression, dementia, memory loss, muscle cramps, joint pain, hair loss, apnea, menorrhagia, pressure symtpoms in neck
67
what are urgent presentation concerns with hashimotos
accumulation of fluid in pleural and pericardiac cavities: admission and drainage myxedema coma is the most severe clinical and must be managed as medical emergency
68
what is the workup for hashimotos
TSH- slightly increased to high T3 and T4 - low positive anti-TPO and TGab US and radioactive iodine untake helps distinguish from graves FNA if malignancy concern CK, prolactin, total cholesterol, LDL, TG - usu. elevated
69
what is the mainstay of treatment for hashimotos/hypothyroidism
thyroid hormone replacement DOC: Titrated levothyroxine sodium PO QD half life of 7 days - early morning on empty stomach
70
what should be avoided when taking titrated levothyroxine sodium
iron or calcium supplements, aluminum hydroxide, proton pump inhibitors, grapefruit or orange juice: causes suboptimal absorption
71
what are other treatment options for hypothyroidism
crtomel (liothyronine) - synthetic T3 armour thyroid ("biologic thyroid replacement")
72
What is Myxedema coma
extreme form of hypothyroidism - medical emergency, rare, high mortality clinical dx
73
what is the presenatation of myxedema coma
weakness, stupor, hypoventilation, hypothermia, hyponatremia, shock and death
74
what is the treatment of myxedema coma
ICU admission, IV levothyroxine, supportive care for respiratory and fluid status
75
What is chronic autoimmune gastritis (CAG)
partial or complete loss of parietal cells leading to impairment of hydrochloric acid and intrinsic factor production develop iron-deficient anemia (micro), leading to pernicious anemia (macro), then severe gastric atrophy
76
What is Cretinism
iodine deficiency
77
What is congenital hypothyroidism from Cretinism
due to a deficiency in thyroid hormone during early fetal development (maternal hypothyroidism during preg), usu. secondary to iodine deficiency
78
What determines iodine deficiency
iodine intake chronically < 20 /day
79
what are signs and symptoms of congential hypothyroidism
intellectual disability, deaf, mute, gait disturbances, short stature, puffy hands and feet, spasticity
80
what are diagnostic tests for thyroid nodule
thyroid ultrasound, TSH, T4 if TSH low: thyroid uptake and scan if nodules > 0.6cm, strongly consider biopsy
81
what are the most common thyroid cancers
papillary thyroid cancer (m/c) follicular thyroid cancer medullary thyroid cancer anaplastic thyroid cancer (ATC) (RARE)
82
what are the risk factors for developing thyroid cancer
F>M radioactive iodine exposure, fhx, childhood head and neck radiation (20-25 years later)
83
what is the clinical presentation of thyroid cancer
painless neck swelling non-tender firm nodule hoarseness neck discomfort dysphagia (compressive symptoms) palpable thyroid nodule, gland may be stony and hard single nodule
84
how do you diagnose/work up thyroid cancer
contingent on cytologic or histologic findings on biopsy childhood radiation hx TSH, T3, T4, TSH may be normal (t3/4 may be elevated) US - anatomic eval - best first step i131 uptake study= functional evaluation FNA
85
what is the treatment of thyroid cancer
surgical resection RAI ablation TSH suppression
86
What is the treatment for ATC CA
little to no role for surgery - local invasion into trachea or vasculature - unresectable 5 year mortality near 100%
87
what are complications of thyroid cancer
locally invasive if untreated - airway, esophagus or neurovascular structures metastatsis: lung, bone, soft tissue surgical complications

Clin Med3: Endocrine (7 decks)

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