Thyroid

Question 1

Asymptomatic or hypothyroidism symptoms - cold intolerance, dry thickened skin, weight gain, menorrhagia
Depression, chronic fatigue, xerostomia, dry eyes

Bradycardia, loss of outer ⅓ of eyebrows, myxedema

RF in Postpartum (hyper →hypo)
Type I DM, autoimmune disorders, FMHx

Answer 1

autoimmune thyroiditis

Question 2

Hashimoto’s–MC thyroid disorder in the US - “chronic lymphocytic thyroiditis”
-Postpartum
-Painless sporadic “hashitoxicosis” from lithium, immunotherapy, amiodarone
Or previous radiation, Turner syndrome, hep C, iodine, pregnancy, interferons, COVID

Answer 2

autoimmune thyroiditis

Question 3

PE: gland diffusely enlarged, firm + finely nodule, painless

LABS: elevated serum antithyroid antibodies, endocrine deficiencies (DM1, hypoparathyroidism, adrenal insufficiency), autoimmune conditions

Primary hypothyroid pattern: increased TSH + decreased free T4

Nodule = FNA

Answer 3

autoimmune thyroiditis

Question 4

how do you treat autoimmune thyroiditis?

Answer 4

treat with levothyroxine, selenium supplement

Question 5

painful neck discomfort, dysphagia, low grade fever, fatigue, sore throat, URI symptoms

Transient hyper→hypo

Viral illness, summer, early autumn

Answer 5

painful subacute thyroiditis

Question 6

de Quervain, granulomatous, giant cell
Result of preceding viral illness or vaccination with recurrence common

Answer 6

painful subacute thyroiditis

Question 7

PE: tender, enlarged thyroid gland

LABS: elevated ESR with low antithyroid antibodies, giant cells on histology

Answer 7

painful subacute thyroiditis

Question 8

how do you treat painful subacute thyroidits?

Answer 8

aspirin or NSAIDs, prednisone if severe pain
Propranolol, iodinated agents for thyrotoxic symptoms

Question 9

febrile, severe pain, tenderness, erythema, fluctuation, pain radiating to ears, jaw, chills common in immunocompomised

Answer 9

suppurative thyroiditis

Question 10

Non-viral infection (staph aureus) think

Answer 10

suppurative thyroiditis

Question 11

LABS: elevated ESR, leukocytosis

Answer 11

suppurative thyroiditis

Question 12

suppurative thyroiditis tx

Answer 12

= staph antibiotics + surgical drainage

Question 13

IgG4: dysphagia, dyspnea, pain, hoarseness

Airway compression
Middle age, older women

Answer 13

IgG4 thyroiditis

Question 14

Rare; Riedel, invasive fibrous, woody - chronic inflammation + dense fibrosis invading thyroid and neck structures

Answer 14

IgG4 thyroiditis

Question 15

PE: asymmetric thyroid enlargement - rock hard, nontender, rapidly growing, fixed goiter
IgG4 serum levels + TPO antibodies

Answer 15

IgG4 thyroiditis

Question 16

how do you treat IgG4 thyroiditis?

Answer 16

long term tamoxifen, steroids

Question 17

Hair loss, lethargy, dry skin, constipation, brittle nails, cold intolerance, anorexia, fatigue, menstrual disturbances (amenorrhea), goiter, high cholesterol, arthralgia

Decreased metabolic processes except for menstrual flow which is increased

Sluggishness, fatigue, memory loss, depression, bradycardia

Answer 17

hypothyroidism

Question 18

Congenital = cretinism (permanent cognitive impairment), iodine therapy, surgical thyroidectomy, TSH deficiency, iodine-deficient diet, drugs (lithium, amiodarone, interferon, PTU, methimazole, chemo), viral, autoimmune (Hashimoto/Graves)
Later stage of thyroiditis
Hashimoto’s = MCC

Answer 18

hypothyroidism

Question 19

what’s the MCC of hypothyroidism

Answer 19

hashimoto’s thyroiditis

Question 20

PE: palpably enlarged, often with nodules, loss out of outer ⅓ eyebrow, non pitting edema

TSH
Free T4
Normal T4 and elevated TSH w/o sx: subclinical hypothyroidism

LABS:
Lipid panel - hypercholesterolemia
CBC - anemia, hypoglycemia
CMP - hyponatremia, GFR, liver enzymes
ANA, antibodies

Answer 20

hypothyroidism

Question 21

how do you treat hypothyroidism

Answer 21

Levothyroxine

TSH, FT4, FT3 monitored every 4-6 weeks until normal – in AM with water only

Subclinical – consider treating when TSH >10 to prevent cardiac complications

Question 22

Severe illness, major surgery
Receiving high dose steroids, dopamine infusions, ICU
Low T4, T3, TSH in patient w/o known thyroid disease

Answer 22

nonthyroidal illness syndrome

Question 23

AMS

Hypothermia, hypoventilation, hyponatremia, hypoglycemia, hypoxemia, hypercapnia, HOTN, rhabdomyolysis, AKI

Elderly women with long-standing hypothyroidism during the winter

Answer 23

myxedema crisis

Question 24

Severe, life-threatening manifestations of hypothyroidism from failure to take prescription levothyroxine, precipitated prolonged exposure to cold, stroke, HF, pneumonia, trauma

Answer 24

myxedema crisis

Question 25

myxedema crisis tx

Answer 25

Levothyroxine bolus → daily treatment, can add liothyronine IV steroids Passive rewarming, fluid resuscitation

Question 26

A fib, hyperreflexia, anxiety, thyroid bruit, diffusely enlarged thyroid Forceful heartbeat, PAC, sinus tachycardia, exertional dyspnea, afib, atrial tachycardia Can cause pulmonary HTN Heat intolerance, weight loss, overall increased metabolic rate Skin warm, moist, soft and fine hair, tremors, nervousness Graves specific = ophthalmopathy + pretibial myxedema

Answer 26

hyperthyroidism "thyrotoxicosis"

Question 27

“Thyrotoxicosis” MCC: Graves disease Or, toxic multinodular goiter (Plummer disease), Hashimoto’s - early stage, pituitary tumor, pregnancy, diet, contrast, amiodarone, iodine (Basedow)

Answer 27

hyperthyroidism

Question 28

Elevated T4 + T3 levels → suppression of TSH If all are elevated = adenoma If antibodies are present = Graves Low TSH but normal T4 and T3 = subclinical RAIU (radioactive iodine uptake scan) = uptake increased in hyperthyroid states + can differentiate between cause Severe → MRI + CT of orbits Diffusely enlarged firm + palpable non tender goiter with or without a thyroid bruit

Answer 28

hyperthyroidism

Question 29

Exophthalmos, dermopathy (red/brown lesions on legs, non-pitting edema) Women, 20-40 Symptoms worsen with stress

Answer 29

grave's

Question 30

Autoimmune disorder – antibodies bind to TSH receptors and continue to stimulate growth, dietary iodine supplementation, amiodarone, HLA-B8, HLA-DR3, viral infections, COVID vaccination

Answer 30

grave's

Question 31

Serum ANA elevation w/o evidence of SLE or other rheum issue Antibodies – TSI or TRab

Answer 31

grave's

Question 32

how do you treat grave's

Answer 32

Propranolol (decrease risk of cardio comps), thiourea drugs (methimazole or propylthiouracil), iodinated contrast agents, lithium , radioactive iodine (NO in pregnancy) Thyroid surgery - large goiters, nodules, malignancy risk Opthalmopathy = IV methylprednisolone

Question 33

Cardiac issues: HF, sinus tachy, v fib, AMS, shock, delirium, high fever with diaphoresis, vomiting, diarrhea, tremors Hyperthyroid manifestations

Answer 33

thyroid storm

Question 34

Life-threatening condition of extreme hyperthyroidism Caused by amiodarone, stress, illness, pregnancy, surgery, sepsis, trauma, RAI Low TSH, increased T4 and T3 (primary)

Answer 34

thyroid storm

Question 35

how do you treat a thyroid storm

Answer 35

ICU → methimazole, iodide, propranolol, IV hydrocortisone, SUPPORT!

Question 36

Mostly asymptomatic – nodules and multinodular goiter can grow, become visible → discomfort, hoarseness, dysphagia

Answer 36

nodules/goiter

Question 37

nodules/goiter are seen more often in

Answer 37

women with hypo or hyperthyroidism

Question 38

when is there concern for malignancy with nodules?

Answer 38

Risk of malignancy higher in large solitary nodules, hoarseness, cervical LAD, men, history of head-neck radiation, personal history of malignancy, familial history, no regression with levothyroxine, cold, elevated calcitonin

Question 39

LABS: thyroid, serum calcitonin Imaging: neck US If TSH is low → RAIU scan If TSH is high → Fine-needle aspiration to assess for malignancy (Skip - concern) Cytopathology indeterminate = molecular testing

Answer 39

thyroid nodules RAIU scan to check hot or cold, with cold being ass w/ malignancy aspiration directly due to high TSH ass w/ malignancy already

Question 40

how do you treat thyroid nodules

Answer 40

Monitored with exam + US every 6 months >2cm + TSH elevated/normal → levothyroxine >3cm and solid = US radiofrequency ablation Surgery if malignancy suspected

Question 41

Lump/swelling in neck, front neck pain, change in voice, trouble swallowing and breathing Follicular goes FAR

Answer 41

thyroid carcinoma

Question 42

Papillary - MC, least aggressive, spreads to cervical lymph nodes, risk from radiation, genetic mutations, familial syndromes Follicular - more aggressive with metastasis to lung, liver, brain, bone Medullary - sporadic, familial, MEN, secretion of calcitonin, prostaglandins, serotonin, ACTH Anaplastic - elderly with rapidly enlarging mass/goiter; most aggressive

Answer 42

thyroid carcinoma

Question 43

Fine needle aspiration with biopsy – some may need histology performed to distinguish between benign and malignant Papillary: biopsy = papillae and nuclear changes Medullary: increased secretion of calcitonin

Answer 43

thyroid carcinoma

Question 44

thryoid carcinoma tx

Answer 44

Surgical resection Anaplastic = secure airway and ensure nutritional support, not often able to resect

Question 45

What does diffuse uptake on RAIU scan mean?

Answer 45

graves or TSH-secreting adenoma on pituitary

Question 46

What does decreased uptake on RAIU scan mean?

Answer 46

thyroiditis

Question 47

What does a hot nodule indicate on RAIU scan?

Answer 47

toxic adenoma

Question 48

What do cold nodules indicate on RAIU?

Answer 48

malignancy

Question 49

How do you treat hyperthyroidism?

Answer 49

1 Antithyroid drugs with no active nodules or cancer– methimazole or propylthiouracil ------Add beta blockers if symptomatic 2 Radioactive iodine ablation of thyroid gland for VERY symptomatic -----Will need permanent hormone replacement 3 Thyroidectomy reserved for nodules, cancer, or pregnancy