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Internal Medicine pt.1 > Thyroid > Flashcards

Thyroid Flashcards

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1
Q

What are the physiological effects of thyroid hormones?

A
  • increase O2 consumption & glucose absorption
  • increase HR, excitability & conductivity
  • increase skeletal & sexual maturation
  • decreases serum cholesterol level
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2
Q

What affects total T3 & T4 measurements

A

Thyroxin binding globulin (TBG)

  • total T4 = 4 - 12
  • total T3 = 80 - 120

increase TBG -> pregnancy, estrogen, congenital
decrease TBG -> liver cell failure, nephrotic syndrome, malnutrition, congenital, androgens

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3
Q

Radio-active iodine uptake (RAIU) is useful in diagnosis of?

A

Hyperthyroidism
except in cases of -> thyrotoxicosis factitia
-> thyroiditis
-> ectopic thyroid tissue (struma ovarii)

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4
Q

What is the most sensitive test for differentiation between primary & secondary thyroid dysfunction?

A

Serum TSH

PRIMARY
hyperthyroidism -> increase T3 & T4 + decreased TSH
hypothyroidism -> decreased T3 & T4 + increased TSH

SECONDARY
hyperthyroidism -> increased T3 & T4 & TSH
hypothyroidism -> decreased T3 & T4 & TSH

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5
Q

What are the anti-thyroid antibodies that could be found?

A
  • Thyroid stimulating immunoglobulin (TSI or LATS) -> Graves’ disease
  • Anti-microsomal & antithyroglobulin -> Hashimoto’s thyroiditis
  • TSH binding inhibitory immunoglobulin (TBII) -> primary hypothyroidism
  • serum thyroglobulin -> increases in differentiated cancer thyroid
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6
Q

What is the significance of thyroid scanning using 99mTC?

A
  • defines areas of hot nodules or cold nodules
  • retrosternal goiter
  • ectopic thyroid tissue
  • functioning metastasis of thyroid carcinoma
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7
Q

What are the causes of thyrotoxicosis?

A

THYROID HYPERFUNCTION

  • Graves disease (Basedow disease)
  • toxic nodule
  • toxic adenoma
  • iodine induced hyperthyroidism
  • TSH-secreting pituitary tumor
  • choriocarcinoma

ABNORMAL THYROID HORMONE RELEASE

  • subacute thyroiditis
  • chronic thyroiditis with transient thyrotoxicosis (Hashitoxicosis)
  • Hamburger thyroiditis

EXTRA-THYROID TISSUE

  • Thyrotoxicosis factitia
  • ectopic thyroid tissue -> Struma ovarii or functioning metastatic follicular carcinoma
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8
Q

What is the cause of Grave’s disease?

A
  • auto-antibody belonging to IGg class -> TSI or LATS (thyroid stimulating immunoglobulin)
  • can lead to transient neonatal thyroiditis because antibodies can cross the placenta
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9
Q

What are the general manifestations of Grave’s disease?

A
  • progressive weight loss + increasing appetite -> hyperdefecation due to increase GIT motility
  • heat intolerance
  • increased sweating
  • nervousness, emotional liability
  • irritable, agitated
  • exaggerated reflexes
  • fine tremors
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10
Q

What are the cardiovascular manifestations of Graves disease?

A
  • all types of arrhythmias EXCEPT heart block
  • high cardiac output failure -> water-hammer pulse
  • flow murmur -> hyper dynamic circulation
  • increase systolic hypertension -> increase pulse pressure
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11
Q

What are the musculoskeletal manifestations of Grave’s disease?

A
  • Myopathy, Myasthenia Graves

- bone resorption -> hypercalcuria & hypercalcemia + osteoporosis

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12
Q

What are the skin manifestations of Graves disease?

A
  • warm with excessive sweating
  • onycholysis -> Plumer nail
  • orange peel thickening of pretibial area
  • clubbing of fingers & toes -> thyroid acropachy
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13
Q

What are the reproductive manifestations of Graves disease?

A
  • women -> oligomenorrhea & deceased fertility

- men -> impotence, decreased sperm count & gynecomastia

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14
Q

What are the ocular manifestations of Graves disease?

A

SPASTIC

  • Roenbach’s sign -> tremors of closed eyelids
  • Stellwag sign -> infrequent blinking
  • Dalrymple sign -> starring look
  • Von Graefe’s sign -> lid lag
  • Joffroy’s sign -> absence of forehead wrinkling

MECHANICAL (infiltrative opthalmopathy)

  • proptosis & ophthalmoplegia (diplopia)
  • Mobius sign -> lack of convergence
  • Conjunctivitis, chemosis, peri-orbital swelling
  • corneal ulceration, optic neuritis & optic atrophy
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15
Q

What are the causes of thyroid storm (thyrotoxicosis crises)?

A
  • excessive manipulation of thyroid during thyroidectomy
  • neglected severe hyperthyroidism + intercurrent illness

Clinical picture -> severeeee

  • tachycardia
  • fever
  • irritability
  • diarrhea
  • psychosis
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16
Q

What are the indications of medical treatment of hyperthyroidism?

A
  • thyrotoxicosis in pregnancy
  • cases complicated by Heart Failure
  • young patients < 25 yo
  • pre medication before surgery
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17
Q

What are the contra-indications of medical treatment of hyperthyroidism?

A
  • huge goiter
  • retrosternal goiter
  • suspicion of malignancy
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18
Q

What are the medications used in hyperthyroidism treatment?

A

THIONAMIDE -> inhibit thyroid peroxidase
- propyl thiouracil -> in pregnancy -> 300 - 600mg -> decrease peripheral production of T3 from T4
- methimazol -> 30 - 60mg
- carbimazol -> 30 - 60mg -> decreases the production of TSI
give for 6 weeks then follow up -> continue for 1 - 2 years

BETA BLOCKERS -> propranolol (inderal)

  • decreases excessive adrenergic activity
  • decreases converge of T4 to T3

Na Ipodate -> decreases T4 to T3 convergence
K. iodine -> decrease vascularity of gland
- used to prepare patient for surgery 10 days prior (5 drops)
Dexamethasone -> decreases secretion of thyroid hormone & T4

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19
Q

What are the side effects of thionamide drugs?

A
  • agranulocytosis
  • arthralgia
  • skin rash
  • serum sickness
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20
Q

What are the indications & contraindications of radiotherapy in hyperthyroidism?

Study These Flashcards
A

Indications

  • recurrence after thyroidectomy
  • failure of medical treatment & unfit patient for surgery
  • patients refusing surgery

Contraindications

  • pregnancy, lactation, & childhood
  • huge & retrosternal goiter
21
Q

What should be the relationship between antithyroid drugs & radiotherapy?

Study These Flashcards
A

antithyroid drugs should be stopped 10 days before radiotherapy & retaken 14 days after

  • so it does not interfere with the uptake of the radio-iodine
  • keep taking antithyroid drugs for a couple of months until the effect of the radiotherapy is apparent
22
Q

What are the side effects of radiotherapy in hyperthyroidism?

Study These Flashcards
A
  • hypothyroidism
  • > if it occurs after 1 month: transient
  • > if it occurs after 1 year: permanent
  • thyroid carcinoma
  • fetal abnormalities & hypothyroidism in newborn if given during pregnancy
23
Q

What are the indications for surgical subtotal thyroidectomy?

Study These Flashcards
A
  • allergy to antithyroid drugs
  • patient refusing radiotherapy
  • big & retrosternal goiters
  • multi nodular toxic goiter
  • malignant suspicion
24
Q

How should a patient be prepared for thyroidectomy?

Study These Flashcards
A
  • thionamide drugs for several months before
  • inorganic iodine 7 - 10 days before surgery
  • beta blockers
25
What are the complications of thyroidectomy?
- hypothyroidism - hypoparathyroidism - recurrent hyperthyroidism - recurrent laryngeal nerve injury
26
How should hyperthyroidism be treated in pregnancy?
- propyl-thiouracil - surgical thyroidectomy if necessary ONLY in first or second trimester - special attention paid to newborn because it can develop hyperthyroidism due to TSI
27
How is thyrotoxic crises treated?
- ice bags, fluids & electrolytes - IV dexamethasone - IV propranolol - Ipodate (Na update) - antithyroid drugs in large doses -> propyl thiouracil 600mg then 300mg every 6 hours - antibiotics - K-iodide
28
What are the non goitrous types of hypothyroidism?
- congenital developmental defect - post surgery - post radiotherapy - idiopathic -> antibodies
29
What are the goiterous types of hypothyroidism?
- Pendred syndrome - endemic goiter -> iodine deficiency - maternally transmitted antithyroid drug or radiotherapy during pregnancy - drug induced - chronic thyroiditis EARLY in disease
30
What are the neurological manifestations of myxoedema?
- reduced memory, mental slowing, dementia -> myxedema madness, depression - delayed relaxation of tendon jerks -> suspended jerks - mucinous infiltration - > flexor retinaculum: carpal tunnel syndrome - > internal ear: progressive deafness - > vocal cords: hoarseness of voice - > tongue: slurred speech
31
What are the cardiovascular manifestations of myxoedema?
- sinus bradycardia -> heart block - cardiomyopathy -> heart failure - cholesterol pericarditis & pericardial effusion - atherosclerosis -> angina pectoris & intermittent claudication - hypertension -> increased peripheral resistance -> increased diastolic BP - hypotension only in myxedema coma - anemia - > normocytic -> bone marrow depression & decreased peripheral O2 requirements - > megaloblastic -> pernicious anemia (Vit B12) - microcytic hypochromic -> menorrhagia & achlorhydria
32
What are the GIT manifestations of myxoedema?
- dynamic ileus -> constipation, obstruction - achlorhydria -> pernicious anemia - ascites -> high cholesterol
33
What are the musculoskeletal manifestations of myxoedema?
- arthralgia - joint effusion - stiff muscles
34
What are the skin & hair manifestations of myxoedema?
- puffy face & coarse features - dry cold skin - orange due to accumulation of carotene - malar flush - sparse, brittle course hair - loss of outer 1/3rd of eyebrow - xanthelasma
35
What are the reproductive manifestations of myxoedema?
- menorrhagia - amenorrhea & galactorrhea (if associated with hyperprolactinaemia) -> increased in TRH - infertility
36
What are the pulmonary & renal manifestations of myxoedema?
Pulmonary - pleural effusion - decreased ventilatory response to hypoxia & hypercapnia -> CO2 narcosis Renal - hyponatremia -> may be due to SIADH
37
What are the metabolic & endocrinal manifestations of myxoedema?
- growth & developmental retardation in children - weight gain & decreased appetite - hypothermia & cold intolerance - hyperlipidemia
38
What are the causes of myxoedema coma?
- long standing untreated hypothyroidism | - hypothyroidism with exposure to -> infection, cold, trauma, CNS depression
39
What is the clinical picture of myxoedema coma?
- subnormal temperature -> 34 - 35 - external features of severe hypothyroidism & bradycardia - dilutional hyponatraemia - alveolar hypoventilation -> CO2 retention & narcosis
40
What investigations are done for myxedema?
- thyroid function - x-ray -> pericardial or pleural effusion - ECG -> low voltage, bradycardia
41
How is myxoedema treated?
L thyroxin -> full effect in 2 - 3 months | - asses T3 & T4 & TSH in 6 weeks
42
what are the indications for rapid correction of hypothyroidism?
- neonatal, infantile, juvenile - myxedema coma - hypothyroid patient preparing for emergency surgery -> IV administration of L-thyroxin + hydrocortisone
43
What are the indications for slow correction of hypothyroidism?
- elderly patients - patients with heart disease -> start with 25 - 50ug/day -> increase 25-50ug every month -> until reaching 150 - 200ug
44
How is myxedema coma managed?
- hydrocortisone 100mg FIRST -> incase associated with adrenal insufficiency - IV L-thyroxin -> 500ug - assisted ventilation - avoid further heat loss
45
What is the cause & clinical picture of subacute thyroiditis? (De Quarvain)
- follows UPPER RESPIRATORY TRACT INFECTION - pain over thyroid or referred to lower jaw, ear, occiput - fever, nodular thyroid, dysphagia
46
What will be found on investigation of subacute thyroiditis & how should it be treated?
- increase T4 due to leakage in the beginning -> euthyroid -> hypothyroid -> recovery - decreased RAIU - increased ESR treat using - aspirin -> in mild cases - prednisone 15-20mg & propranolol -> in severe cases
47
What is chronic lymphocytic thyroiditis?
HASHIMOTO'S -> autoimmune chronic thyroid inflammation - increase T4 initially -> hypothyroidism later - high tire of antimicrosomal antibodies -> could lead to Hashitoxicosis treat using levothyroxin
48
What are the high risk factors for malignancy in a thyroid nodule?
HISTORY - head & neck irradiation - nuclear radiation exposure - rapid growth - recent onset - young age - male - familial (medullary then papillary) PHYSICAL EXAM - hard nodule - fixed - lymphadenopathy - vocal cord paralysis - distant metastasis LAB & IMAGING - elevated calcitonin - cold nodule on technetium - solid lesion with micro calcification on US

Internal Medicine pt.1 (33 decks)

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