ENDO-HYPER

Question 1

What is the MCC of Hyperthyroidism

Answer 1

autoimmune- Graves disease

1] Toxic nodular goiter (single or multinodular),
2] Thyroiditis (subacute, painless, postpartum),
3] TSH producing adenoma (rare)

Question 2

Pt c/o Weight loss,
 insomnia, 
anxiety, irritability,
heat intolerance, 
palpitations, tremors, 
frequent bowel movements,
muscle weakness, 
hair loss, oily skin, 
amenorrhea

Answer 2

Hyperthyroidism

Question 3

PT has the following on PE. What is DX? 
tachycardia, 
diaphoresis-sweating
diffuse palpable goiter, 
thyroid bruit, 
fine tremor, 
opthalmopathy (proptosis, lid retraction, 
chemosis-edema in eye

Answer 3

Hyperthyroidism vitals

Question 4

why the thyroid bruit occurs in Hyperthyroidism?

Answer 4

increased blood flow in goiter

Question 5

What are the cardivacular findings in Hyperthyroidism

Answer 5

sinus tachycardia,
systolic flow murmurs,
atrial fibrillation,
prominent API-arterial pulse pressure

Question 6

Who is more comonly affected by Graves disease

Answer 6

Women 20-40, FH, autoimmune/thyroid disease common

autoantibodies to TSH receptor (TRAb, TSHRAb, TSI, TBII), Abs bind and activate TSH receptors
stimulate thyroid hormone production and thyroid growth

Question 7

Describe the laboratory findings of Graves disease

Answer 7

low TSH, HIGH T4/ T3, positive thyroid antibodies

Question 8

What is the unique clinical presentation of Graves disease

Answer 8

Opthalmopathy- not found in other causes of hyperthyroidism.

2% of all cases

Question 9

Describe Infiltrative Opthalmopathy

Answer 9

Inflammation of the extraocular muscles, connective and adipose tissue

Smoking makes worse

Question 10

What is the management for Graves disease

Answer 10

1] Refer to endocrinology,
2] Anti-thyroid meds (thionamides),
3] TSH, FT4, FT3 monitored after 3-4 weeks and then q 2-3 months.

Goal is euthyroidism.

Question 11

Describe the Anti-thyroid meds

Answer 11

1] propylthiouracil (PTU) and methimazole: inhibit thyroid hormone synthesis,
2] Methimazole preferred (once daily dosing, more rapid efficacy, lower incidence of side effects),

3] Treatment can continue 12-24 months with possibility of remission (20-30%)

Question 12

What are the side effects of methimazole

Answer 12

agranulocytosis/neutropenia.

baseline CBC w/diff prior to tx and monitor during tx.

Neutropenia-first couple months and higher dose of therapy increases likelihood of ADE.

Question 13

What are the side effects of PTU

Answer 13

hepatoxicity, agranulocytosis

monitor LFT’s, CBC

Question 14

Describe definitive treatment for Graves disease

Answer 14

euthyroid with medication(3-8 weeks),

proceed with radioactive iodine ablation (RAI)
permanent solution to hyperthyroidism,
permanent hypothyroidism- need lifelong thyroid replacement
Usually two part series- radioactive iodine uptake and scan then nuclear med radiologist uses that information to determine appropriate dose of iodine for radioactive iodine ablation (patient returns 1-2 days later for ablation)

Question 15

Describe the use of beta blockers for Graves disease

Answer 15

symptomatic relief (tachycardia, anxiety, tremulousness, heat intolerance)

Question 16

How does atrial fib due to hyperthyroidism

Answer 16

because too much thyroid hormone irritates the heart

Question 17

How does CHF due to hyperthyroidism

Answer 17

increased HR, palpitations,
causing ventricular hypertrophy-to thick to expand, less vol. less out
decreased cardiac output= SVxHR

Question 18

How does Bone loss due to hyperthyroidism

Answer 18

thyroid hormone increases bone turnover= more osteoclast activity

Question 19

Describe the thyroid storm

Answer 19

Rare, life-threatening condition (Mortality rate- 20-30%) severe hyperthyroidism with cardiac manifestations , untreated hyperthyroidism;
Eitiology- acute event (surgery, trauma, infection, acute iodine load, childbirth). Body overdrive to fix problme

Question 20

PT tachycardia, cardiac arrhythmia, hyperpyrexia, n/v/d; may progress to delerium, psychosis, comaDescribe the clinical features of thyroid storm

Answer 20

S/S of THYROID STORM

Question 21

What is 2nd MC after Graves? Who? DX tool? TX

Answer 21

Nodular areas hypersensitive to TSH stimulation,
resulting in nodules excessive amounts of thyroxine,

Who? Elderly

DX-Thyroid uptake scan can determine presence of “hot”- iodine uptake

beta blockers, thionamides
permanent solution -adioactive iodine ablation(RAI), surgery

Question 22

Describe the thyroid scintigraphy (uptake and scan)

Answer 22

Diff btwn throiditis and hyperthyoidism

an iodine uptake test-
a scan (imaging) with a gamma camera.-returns 24 hours later to have the level of radioiodine, metal bar measures the radioactivity emitting from the thyroid.

Question 23

PT c/o-Fever, fatigue and lethargy with mild, 2-8 weeks post URI
PE- + Thyroid is tender and diffusely enlarged

Answer 23

Subacute Thyroiditis-viral infection or postviral inflammatory process
transient hyperthyroidism initially, followed by transient hypothyroidism,

self-limited non suppurative inflammation with abrupt

onset of pain in the thyroid that radiates to the ear, jaw and neck,

Question 24

How do you treat of Subacute Thyroiditis

Answer 24

symptomatic: NSAID, prednisone;

Full recovery is common

Question 25

PT c/o-Fever, fatigue and lethargy with mild, 2-8 weeks post URI PE- + Thyroid gland is not painful or tender What is next step in TX

Answer 25

Painless/Silent thyroiditis Transient mild hyperthyroidism, sometimes followed by hypothyroidism, then recovery TX-symptomatic (beta blocker, short course of thyroxine)

Question 26

What are the lab findings of Thyroiditis

Answer 26

Labs often indicate low TSH, elevated T4, T3 can be normal or slightly elevated, and elevated ESR

Question 27

Describe Postpartum thyroiditis

Answer 27

A variant form of Hashimoto’s thyroiditis (+ TPOAb), one year of parturition-mistaken for post partum depression; Typically hyperthyroid phase followed by hypothyroidism NO tx needed symptomatic relief during hyper/hypo phases (beta blocker, thyroxine); Most women recover completely, but 30% have permanent hypothyroidism ***

Question 28

Describe incidence rate of thyroid nodules

Answer 28

90% are benign adenomas/cysts; 50% of the population between ages 30-60; 10% are lesions low grade malignancy agressively thyroid cancer-RARE

Question 29

What are solitary thyroid nodules? What are next steps?

Answer 29

benign adenomas with hypofunction; endocrinologist with 1] Thyroid ultrasounds should be performed on all patients with suspected nodule,-size, consistency, characteristics, and number of nodules 2] Thyroid uptake/scan

Question 30

Ultrasound guided fine needle aspiration (FNA) biopsy results management

Answer 30

1] If benign adenoma with nml TFT’s , no tx necessary, annual ultrasounds, 2] If cystic aspirate; repeat 6-12 months, 3] If FNA cytology positive for thyroid cancer: begin aggressive treatment

Question 31

MC malignant neoplasms of the endocrine system;

Answer 31

Thyroid Carcinoma

Question 32

Describe Thyroid Carcinoma risk factors. What is key to early dx?

Answer 32

history of irradiation to the head and neck, FH 1] Routine screening with ultrasound and FNA thyroid nodules is key 2] Aggressive treatment to prevent early metastasis

Question 33

What findings solid nodules with increase in size from prior study, presence of microcalcifications mean?

Answer 33

Thyroid Carcinoma

Question 34

List the Classification of Thyroid Carcinoma

Answer 34

1] Papillary-MC,-Most common and most benign, 80% of all thyroid cancers are papillary type 2] Follicular, 3] Medullary, 4] Anaplastic-

Question 35

cause, prognosis, risk tx of Papillary Thyroid Carcinoma

Answer 35

ETI-genetic, radiation exposure Prognosis- Positive lymph nodes of the neck in > 50% cases-Distant spread uncommon. near 100% cure for small lesions in young patients distant metastasis-inc mortality

Question 36

What is the treatment of Papillary Thyroid Carcinoma

Answer 36

total thyroidectomy, followed by RAI ablation, TSH suppression therapy

Question 37

Describe the incidence rate of Follicular Thyroid Carcinoma

Answer 37

second most common, Peak onset ages 40-60, Occurs in females > males (3:1), Rarely associated with radiation exposure

Question 38

Describe Medullary Thyroid Carcinoma

Answer 38

Neuroendocrine tumor that produces calcitonin 3-5% of all thyroid cancers; Females affected more than males; Not associated with radiation exposure

Question 39

Describe the incidence rate of Anaplastic Thyroid Carcinoma

Answer 39

1% of all thyroid carcinomas; Males age 60 Prognoisis- high mortality rate 5 year survival rate around 5%