Endocrine Conditions

Question 1

Risk factors for Hypothyroidism include

Answer 1

-elderly age
-women
-down syndrome
-medications (iodide amiodarone, lithium
interferon-alpha, interleuken-2)
-postpartum (transient period)
-personal/family history of autoimmune
-head and neck irradiation or surgery

Question 2

Medications that can affect or cause damage to the thyroid gland (hypothyroid ism & hyperthyroidism)

Answer 2

-iodide (hypothyroidism)
-amiodarone, lithium (capable of inducing both hyperthyroidism and hypothyroidism as well as thyroiditis)
-interferon-alpha, interleuken-2

Question 3

What is the most helpful measurement of thyroid dysfunction?

Answer 3

TSH (thyrotropin)

Question 4

Characteristic causes of hyperthyroidism include

Answer 4

• Excessive energy release
  -rapid cell turnover

Question 5

What are some causes for hyperthyroidism

Answer 5

-Graves’ disease
-thyroiditis
-metabolically active thyroid nodule

Question 6

S/S of hyperthyroidism

Answer 6

-Nervousness, irritability, memory problems
-Weight loss (50% cases 5-10 lbs)
-Heat intolerance
-Skin - Smooth, silky skin
-Hair: Fine hair w/frequent loss
-Nails: Thin nails break with ease
-GI: Frequent, low-volume, loose stools;
hyper defecation
-Amenorrhea or low-volume menstrual flow
-Reflexes: Hyperreflexia with a characteristic “quick out–quick back” action
Muscle: Proximal muscle weakness
-Cardiac: Tachycardia

Question 7

Characteristics of Hypothyroidism

Answer 7

-Reduced energy release
-slow cell turnover

Question 8

Causes of Hypothyroidism

Answer 8

-Post–autoimmune thyroiditis (>95% in North America)
-primary pituitary failure (rare world
wide).
-Dietary iodine deficiency most common
reason for hypothyroidism worldwide but
relatively uncommon in North America

Question 9

What is the most common reason for hypothyroidism worldwide but relatively uncommon in North America

Answer 9

Dietary iodine deficiency

Question 10

S/S of Hypothyroidism

Answer 10

-Lethargy, uninterest, memory problems
-Weight gain (usually 5–10 lb [2.3–4.5 (largely fluid, little fat)
-Chilling easily, cold intolerance
Skin: Coarse, dry skin
Hair: Thick, coarse hair w/tendency to break easily
-Nails: Thick, dry nails
-GI: Constipation
- Menorrhagia
-Reflexes: hyporeflexia with characteristic slow relaxation phase, the “hung-up” patellar deep tendon reflex
-Muscle: usually no change
-Cardiac: bradycardia severe cases

Question 11

What produces TSH and what is it stimulated by through what kind of feedback loop

Answer 11

-released by the anterior lobe of the pituitary
-negative feedback loop in response to the amount of circulating thyroid hormone (T4).

Question 12

What is the best lab value to indicate abnormal TSH levels?

Answer 12

free T4

Question 13

What thyroid level is known as a “prodrug for T3?

Answer 13

T4 thyroid hormone

Question 14

If TSH levels are normal what is also likely to be normal levels

Answer 14

free T4

Question 15

When should free T4 levels be checked if TSH is elevated or undetectable?

Answer 15

hypothyroidism should be
confirmed by obtaining free T4 level.

Question 16

Preventive Services Task Force (USPSTF) recommendations on routine thyroid testing?

Answer 16

advise that there is insufficient evidence to
recommend for or against routine screening for all asymptomatic lower risk adults, for thyroid disease

Question 17

What condition is characteristic of chronic lymphocytic thyroiditis

Answer 17

Hashimoto’s thyroiditis

Question 18

What thyroid condition is a dominant trait and is often associated with what autoimmune disorders?

Answer 18

-Hypothyroidism/Hashimoto’s thyroiditis
autoimmune disorders: pernicious anemia, rheumatoid arthritis, DM, and Sjögren’s
syndrome

Question 19

Etiology of Hashimoto’s Thyroiditis

Answer 19

-most common in countries lacking iodine
-likely genetic predisposition
-condition is most often seen in women 30 to 50 years old clinical presentation often includes a ,

Question 20

Clinical presentation of Hashimoto’s Thyroiditis (hypo thyroid)

Answer 20

diffusely enlarged, firm thyroid w/ fine nodules,
-neck pain, and tightness
-goiter may regress over time
-many individuals first present with the condition in the hypothyroid state
-may see typical hypothyroid S/S

Question 21

What is the treatment for Hashimoto’s Thyroiditis’s

Answer 21

-T4 replacement
-in the form of levothyroxine (Levothroid®, Levoxyl®, Synthroid®, Unithroid®,generic).

Question 22

What type of antibodies are often present in person with Hashimoto’s Thyroiditis?

Answer 22

Antimicrosomal thyroid antibodies, also known as thyroid peroxidase (TPO) antibodies
-likely reflecting cell mediated immunity, are found in nearly all patients with

Question 23

What disease is the most common cause of thyrotoxicosis?

Answer 23

Graves’ Disease (hyper thyroid)

Question 24

Clinical presentation of Graves’ diseas

Answer 24

-diffuse thyroid enlargement, –exophthalmos,
-nervousness
-tachycardia
-heat intolerance.

Question 24

Age of onset and associated autoimmune disorders common with Graves's Disease

Answer 24

20-40 year -pernicious anemia, myasthenia gravis, DM1

Question 25

A scan of the thyroid for someone with Graves Disease would revele

Answer 25

-Thyroid scan reveals a large “hot” (metabolically active) gland with heterogeneous uptake

Question 26

Treatment for Graves' Disease (hyper thyroid)

Answer 26

-use of antithyroid preparations methimazole or propylthiouracil -the use of both drugs carries a hepatotoxicity warning -Once euthyroid status is achieved, radioactive iodine for thyroid ablation is usually the next step in therapy -Subsequent hypothyroidism is the norm, necessitating the use of levothyroxine -Expert consultation is advised in caring for the person with hyperthyroidism.

Question 27

What is a diagnosis of subclinical hypothyroidism based on

Answer 27

-presence of an elevated TSH level and a normal free T4 level -in the absence of or with minimal symptoms Goiter, or chronic thyroid enlargement, usually caused by hypertrophic or degenerative changes, is a common finding but is also found in many individuals with normal thyroid function or other forms of thyroid disease.

Question 28

Most common complaint in a person with untreated hypothyroidism is

Answer 28

fatigue

Question 29

Value of TSH for subclinical hypothyroidism

Answer 29

TSH values of 5 to 10 mIU/L; 50% to 80% have evidence of thyroid peroxidase (TPO) antibodies

Question 30

2 Treatment modalities for subclinical hypothyroidism

Answer 30

-matter of differing approaches -recommend levothyroxine therapy in the presence of TPO antibodies - watch and wait approach versus a watch-and-wait approach,

Question 31

Under a watch and wait treatment for hypothyroidism how often should you check? What TSH and free T4 levels are indications for treatment with levothyroxine therapy?

Answer 31

-Periodic TSH and free T4 testing every 6 months -When TSH level increases to more than 10 mIU/L, even in the presence of a normal free T4 level, -a significant increase in LDL, -increasing cardiovascular disease risk, -levothyroxine therapy should be initiated

Question 32

The American Association of Clinical Endocrinologists guidelines recommend treatment of patients with TSH greater than 5 mIU/L if

Answer 32

-patient has a goiter -TPO antibodies are present -presence of symptoms compatible with hypothyroidism -infertility/ pregnancy or plans to become pregnant in the near future also favors treatment (hypothyroid prior to)

Question 33

Treatment with levothyroxine for hypothyroidism (dosing recommendations)

Answer 33

-1.6 mcg/kg/d, based on ideal body weight; -actual body weight should be used for the person who is underweight A lower dose is recommended for older adults -In the presence of subclinical hypothyroidism, a relatively low levothyroxine dose is often sufficient because some thyroid function remains -Over time, thyroid failure progresses, and the patient’s levothyroxine requirement typically increases.

Question 34

If you adjust a patient's levothyroxine dosage, when should you check again to see if levels are normal

Answer 34

6-8 weeks

Question 35

Why does a provider need to wait 6-8 wks before checking new levels

Answer 35

Because this drug has a long half life, the effects of a dosage adjustment would not cause a change in TSH for approximately five to six drug half-lives

Question 36

What does and NP need to know about animal desiccated thyroid (Armour)?

Answer 36

-Animal-derived desiccated thyroid such as Armour® thyroid contains T4 and T3; drug levels vary substantially -thyroid levels will vary throughout the day in those taking desiccated thyroid -use of desiccated thyroid medication is not well studied and not a well-supported drug for treatment -Desiccated thyroid is animal-sourced, either bovine (cow) or porcine (pig) in nature; -the use of the medication would likely pose difficulties for certain ethnic and religious groups as well as vegans and vegetarians. - this product contains a fixed dose of T3 and T4. -its pharmacokinetics differ significantly when compared to levothyroxine

Question 37

Increased risk of thyroid disorder is found in individuals who are: A. obese. B. hypertensive. C. treated with systemic corticosteroids. D. elderly

Answer 37

elderly

Question 38

A 48-year-old woman with newly diagnosed hypothyroidism asks about a “natural thyroid” medication she read about online and provides the drug’s name: desiccated thyroid. As you counsel her about this medication, you consider all of the following (select all that apply) A. this product contains a fixed dose of T3 and T4. B. the medication is a plant-based product. C. its pharmacokinetics differ significantly when compared to levothyroxine. D. the majority of the study on treatment for hypothyroidism has been done using levothyroxine

Answer 38

A. this product contains a fixed dose of T3 and T4. C. its pharmacokinetics differ significantly when compared to levothyroxine. D. the majority of the study on treatment for hypothyroidism has been done using levothyroxine

Question 39

Hypothyroidism most often develops as a result of: A. primary pituitary failure B. thyroid neoplasia. C. autoimmune thyroiditis. D. radioactive iodine exposure

Answer 39

autoimmune thyroiditis

Question 40

Which is following is the least helpful test for the assessment of thyroid disease? A. total T4 B. thyroid-stimulating hormone (TSH) C. free T4 D. thyroid peroxidase (TPO) antibodies

Answer 40

A. total T4

Question 41

Physical examination findings in patients with Graves’ disease include: A. muscle tenderness B. coarse, dry skin C. eyelid retraction. D. delayed relaxation phase of the patellar reflex

Answer 41

C. eyelid retraction.

Question 42

The mechanism of action of radioactive iodine in the treatment of Graves’ disease is to: A. destroy the overactive thyroid tissue. B. reduce production of TSH. C. alter thyroid metabolic rate. D. relieve distress caused by increased thyroid size

Answer 42

A. destroy the overactive thyroid tissue. Hypothyroidism can then present and T4 replacement (levyothyroxine)

Question 43

Which of the following medications is a helpful treatment option for relief of tremor and tachycardia seen with untreated hyperthyroidism? A. propranolol B. diazepam C. carbamazepine D. verapamil

Answer 43

A. propranolol

Question 44

In prescribing levothyroxine therapy for an elderly patient, which of the following statements is true? A. Elderly persons require a rapid initiation of levothyroxine therapy. B. TSH should be checked about 2 days after dosage adjustment. C. The levothyroxine dose needed by elderly persons is 75% or less of that needed by younger adults. D.TSH should be suppressed to a nondetectable level

Answer 44

C. The levothyroxine dose needed by elderly persons is 75% or less of that needed by younger adults.

Question 45

heat intolerance

Question 46

smooth, silky skin

Question 47

98. goiter

Question 48

99. frequent, low-volume, loose stools

Question 49

100. secondary hypertriglyceridemia

Question 50

101. amenorrhea or oligomenorrhea

Question 51

102. coarse, dry skin

Question 52

103. menorrhagia

Question 53

104. hyperreflexia with a characteristic “quick out–quick back” action at the patellar reflex

Question 54

105. proximal muscle weakness

Question 55

106. tachycardia with hypertension

Question 56

107. hyporeflexia with a characteristic slow relaxation phase, the “hung-up” reflex

Question 57

108. coarse hair with tendency to break easily

Question 58

109. thick, dry nails

Question 59

110. constipation

Question 60

111. atypical presentation in an elderly

Question 61

112. change in mental status

Question 62

The use of which of the following medications can induce thyroid dysfunction? A. sertraline B. venlafaxine C. bupropion D. lithium

Answer 62

Lithium

Question 63

What do these levels reveal? TSH = 8.9 mIU/L (0.4 to 4.0 mIU/L); free T4 = 15 pmol/L (10 to 27 pmol/L)

Question 64

What do these levels reveal? TSH less than 0.15 mIU/L (0.4 to 4.0 mIU/L); free T4 = 79 pmol/L (10 to 27 pmol/L)

Question 65

What do these levels reveal? TSH = 24 mIU/L (0.4 to 4.0 mIU/L); free T4 = 3 pmol/L (10 to 27 pmol/L)

Question 66

TSH serum levels (normal)

Question 67

T4 serum levels (normal)

Question 68

Free T4 serum levels (normal)

Question 69

T3 serum levels (normal)

Question 70

What should be first line therapy for hyperlipidemia?

Answer 70

Intensive therapeutic lifestyle changes should be the first line of therapy

Question 71

What are dietary/lifestyle recommendations for the management of hyperlipidemia

Answer 71

-reducing saturated fat and cholesterol intake and -adding dietary options to enhance LDL lowering (plant stanols and sterols) and -increasing intake of viscous or soluble fiber -weight management -regular aerobic exercise

Answer 72

weight managment and regualr aerobic exrcise for everyone for the managment of hyperlipidemia