thyroid Flashcards
(113 cards)
1
Q
what is Primary hyperthyroidism
A
is when the problem is within the thyroid.
2
Q
what is secondary hyperthyroidism
A
when the problem is with something else in the body which is affecting the thyroid like the pituitary or hypothalamus
3
Q
the most common cause of hyperthyroidism
A
Graves disease is the most common cause of hyperthyroidism. It is an auto immune disease in which the body creates antibodies that bond to the TSH receptor thereby forcing the thyroid into excessive production.
4
Q
medication that may cause thyrotoxicosis
A
amiodarone
5
Q
hyperthyroidism gender and age
A
women > men 8:1; ages 20-40
6
Q
second common cause of hyperthyroidism
A
toxic multinodular goiter
7
Q
pregnancy, excessive dietary iodine intake, radiographic contrast, pituitary tumor, hashimoto’s thyroiditis
A
other causes of hyperthyroidism
8
Q
thyroid cancer an graves
A
they can coincide
9
Q
Grave’s disease 20-40% of pts will have…
-risk higher in who
A
chemosis(swelling of conjunctiva)
conjunctivitis
exophthalmos or proptosis
-risk higher in smokers
10
Q
Eyes: stare lid lag with downward gaze upper eyelid retraction diplopia
A
hyperthyroidism
11
Q
Heart Tachycardia AFib(8% of pts-usually elderly men w/ hrt d/s) Palpitations/forceful heartbeat Chest pain PVCs
A
hyperthyroidism
12
Q
Skin Fine hair warm moist onycholysis (painless detachment of the nail from the nail bed) 3% have myxedema(dermal edema)
A
hyperthyroidism
myxedema in hypothyroidism too
13
Q
change in bowel habits, menorrhagia, brittle hair, heat intolerance
A
hyperthyroidism
14
Q
reflexes in hyperthyroidism
A
brisk HYPER-reflexia
15
Q
osteoporosis clubbing finger swelling hypercalcemia/nephrocalcinosis gynecomastia AFib decreased libido/sperm count/impotence
A
Chronic symptoms hyperthyroidism/thyrotoxicosis
16
Q
fever tachycardia vomiting/diarrhea dehydration muscle weakness confusion
A
thyroid storm
17
Q
what can develop following oral or IV carbohydrates, IV dextrose, or excessive exercise
A
15% develop hypokalemic periodic paralysis lasting 7-72 hours typically in Asian and Native American Men
18
Q
Hyperthyroid blood work
A
TSH extremely low (almost all the time) T4 (thyroxine) elevated T3 (triiodothyronine ) ESR elevated TSH receptor antibody elevated in Graves disease hypercalcemia
19
Q
graves disease antibodies
A
peroxidase antibodies and thyroglobulin antibodies
20
Q
radioactive iodine uptake study
A
increased uptake in graves and toxic multinodular goiter; uptake is more diffuse and symmetric in graves
21
Q
avoid radioactive iodine uptake study in who
A
never should be done in pregnant women or in those with laboratory confirmed disease
22
Q
imaging for hyperthyroidism
A
MRI and CT scanning of orbis is performed for severe or unilateral ocular signs or when causation may be other than graves
23
Q
hyperthyroidism first line tx
A
Beta blockers are the first line of treatment and propranolol is the one you will hear about with hyperthyroidism and thyroid storm
24
Q
what meds to control hyperthyroidism
A
Methimazole(MMI) and propylthiourcial (PTU) will actually control hyperthyroidism. radioactive iodine ablates thyroid(MC)
25
what meds to treat afib with hyperthyroidism
Digoxin to treat AFib
| Warfarin to treat clotting with AFib
26
procedures for hyperthyroidism
Radioactive Iodine ablation
| Surgical removal
27
drug of choice pregnancy or breast feeding with hyperthyroidism
PTU
28
radioactive iodine ablation for who
older pts, those with prior PTU/MMI reaction or failure, or poor compliance
29
older pts, those with prior PTU/MMI reaction or failure, or poor compliance: hyperthyroidism tx
radioactive iodine ablation
30
afib from hyperthyroidism tx
digoxin in large doses and beta blockers
31
opthalmopathy from hyperthyroidism tx
IV methylpredisone
32
RAI administration, pregnancy, trauma, sepsis, illness
all can precipitate a thyroid storm
33
thyroid storm mortality
high
34
PTU for thyroid storm- administer how
- orally but monitor for liver dysfunction
- IV Na iodine may be considered as well as IV hydrocortisone 50-100 mg every 6 hrs
- iodine may be administered as lugol solution
35
how to alleviate thyroid storm symptoms
propanolol
36
how to treat hypokalemic periodic paralysis
- medication and MOA
- avoid what
propanolol- normalizes serum potassim and phosphate levels and reverses paralysis within 3 hrs
- avoid IV dextrose or oral carbohydrates
37
heat vs cold intolerance
heat is hyperthyroidism
38
pts presents with afib, fever, delirium
- disease
- tx
thyroid storm
| - anti-thyroid drugs, then iodine, IV esmolol, steroids, admit
39
hyperthyroidism intial test
TSH then T4
40
hyperthyroidism definitive tx
radioactive thyroid ablation or total thyroidectomy
| - give levothyroxine (oral T4) and steroids
41
1st and 2nd most common endocrine disorder in US
1st is diabetes, 2nd is hypothyroidism
42
hypothyroidism is autoimmune and this causes what
| -what causes the disease
antibodies against TSH receptors, antiperoxidase, and thyroglobulin
- anti-TSH antibodies cause the disease. antiperoxidase and antithyroglobulin are disease markers
43
most common cause of hypothyroidism
hashimotos thyroiditis
44
Medications that can cause hypothyroidism
Amiodarone which is structurally similar to thyroxine
Lithium
Propylthiouracil (PTU) and Methimazole – used to control hyperthyroidism
45
hypothyroidism labs
add CBC and BMP findings
what imaging
**TSH — elevated in primary hypothyroidism.
total T4 — decreased; free T4 — decreased
T3 — may be normal
Antithyroid peroxidase andAntithyroglobulin antibodies
CBC — may show anemia from iron def or chr disease (decreased absorption of iron and folate as well as GI motility)
BMP — low sodium(from alteration of renal tubular Na reabsorption)
imaging only if a concern for malignancy
46
up to 30% of downs pts will have this
hypothyroidism
47
labs in euthyroid state
nml or low free T4 and TSH
48
labs in primary hypothyroid state
low free T4 and elevated TSH
49
labs in secondary hypothyroid state
low free T4 and low/nml TSH
50
levothyroxine
converts to T3. adjust dose every 4-6 weeks based on TSH value
- assess for adrenal insufficiency and angina
51
severe hypothyroidism
- disorder
- presentation
- hallmark symptom
- mortality
myxedema crisis- obtundation, CO2 retention, maybe coma
** altered mental status
mortality 20-30%
52
```
pt presents with ...
mental changes from confusion to coma
convulsions
hypotension
hypothermia
hypoventilation
rhabdomyolysis and acute kidney damage
hyponatremia
hypoglycemia
acute kidney injury
```
myxedema crisis
53
myxedema crisis tx
IV levothyroxine or thyroxine bolus
consider hydrocortisone if adrenal insufficiency is suspected
intubation if necassary
slow warming with warm blankets if necessary
54
suppurative thyroiditis organism
st aureus
55
thyroiditis dx tests
FNA with gm stain and culture
56
most common cause of sporadic goiter in kids
hashimoto
57
Sjogren’s syndrome
xerostomia — dry mouth
| keratoconjuctivitis — dry eyes
58
hashimoto
- gender
- FH?
- what has the incidence risen over the past 50 years?
- female 6 times more likely
- may be familial
- related to increase in iodine content in diet
59
hashimoto may also present with what
- 30% will have sjogrens syndrome
| - often concomitant with myasthensia gravis
60
most common painful thyroid gland
subacute
61
```
acute pain to thyroid
glandular enlargement → dysphagia
low grade fever
fatigue
dysphagia/otalgia for months
?thyrotoxicosis
```
Subacute Thyroiditis
50% will have thyrotoxicosis followed by hypothyroid followed by euthyroid within 12 months
62
50% will have thyrotoxicosis followed by hypothyroid followed by euthyroid within 12 months
Subacute Thyroiditis
63
EBV, influenza, coxsackie virus, mumps, measles, adenovirus
can all cause subacute thyroiditis
64
Subacute thyroiditis tx
- Aspirin is the first line drug of choice for pain and inflammation
- Propranolol (betablocker) for symptoms of hyperthyroid
- Levothyroxine for symptoms of hypothyroid
- no benefit of steroids
65
Subacute thyroiditis labs
markedly elevated ESR with antithyroid antibody titers low
66
```
thyroid: disease and etiology
painful
tender
red
fluctuant
```
Suppurative Thyroiditis
| st aureus
67
hashimoto's with a thyroid nodule
A patient with Hashimoto’s thyroiditis and a nodule in the thyroid should undergo FNA as the risk of associated thyroid cancer is significant
68
```
hypothyroid symptoms
the thyroid becomes enlarged and hard
dysphagia
hoarseness
pain
dyspnea
typically goes along with systemic fibrosis
```
Reidel thyroiditis
69
Reidel thyroiditis tx
short course of steroids for symptomatic relief
| Tamoxifen for years after will result in partial to complete remission
70
woody assymetric hard thyroid
reidel
71
Reidel thyroiditis
- gender
- common or rare
80% females
| the rarest
72
2 rare thyroiditis
suppurative and reidel
73
drug induced thyroiditis
- from what
- half life
- serum increase in what
- results in what
- amiodarone: causes thyroid dysregulation in 20% of pts due to iodine content
- 100 day half life
- cause serum increase of T4 by 20-40% during first month but causes cellular resistance to T4.
- resultant hypothyroid picture ensues with elevated TSH and symptoms typical of hypothyroidism
74
aspirin tx for what
subacute painful thyroiditis
75
tamoxifen tx for what
riedel thyroiditis
76
steroids tx for what
suppurative thyroiditis
77
leukocytosis and increased ESR for what thyroiditis
suppurative
78
subacute thyroiditis peaks what season
| and ages
summer
| young and middle aged women
79
believed to be autoimmune in nature
| occurs in 7.2% of women post delivery
Postpartum thyroiditis
80
hyperthyroid followed by hypothyroid
painless
palpable goiter
beings 1-6 months postpartum
Postpartum Thyroiditis
| beings 1-6 months postpartum
81
Postpartum Thyroiditis tx
self limiting
82
imaging in thyroiditis
- U/S used to distinguish thyroiditis from nodular goiter or possible malagnancy
- Radioiodine uptake scan may be helpful
83
thyroiditis labs
TSH
T4
Antithyroperoxidase levels increased in 90% of Hashimoto’s thyroiditis
Antithyroglobulin antibodies increased in 40% of Hashimoto’s thyroiditis
Thyroid autoantibodies
sed rate
84
Antithyroperoxidase levels increased in 90% of ___ thyroiditis
Antithyroglobulin antibodies increased in 40% of ___ thyroiditis
Antithyroperoxidase levels increased in 90% of Hashimoto’s thyroiditis
Antithyroglobulin antibodies increased in 40% of Hashimoto’s thyroiditis
85
endemic goiters
% of population
found where
10%
| found in iodine deficient areas
86
sorghum, millet, maize, cassava, mineral deficiencies of selenium and iron
may enhance risk in iodine deficient states
87
solitary thyroid nodule
- gender
- size
- symptoms
- benign or malignant
females
over 1 cm
asymptomatic
benign usually. only 5% of palpable nodules are malignant
88
what solitary thyroid nodules are encapsulated
nodule of an adenoma is encapsulated, but the nodules of multinodular goiters are not encapsulated
89
most common type and rare type of solitary thyroid nodule
common: follicular adenoma
rare: papillary adenomas
90
hurtle cell
solitary thyroid nodule that has eosinophilic staining and has malignant potential
91
adenomas cancerous?
true adenomas are not cancer precursors
92
solitary thyroid nodule workup:
| if TSH is low
assess for hyperthyroidism and undergo radionuclide thyroid scan
93
most sensitive test for a solitary thyroid nodule
high resolution ultrasonography
94
why u/s over a CT for a solitary thyroid nodule
u/s has higher accuracy, lower cost, and lack of radiation
95
solitary thyroid nodule has irregular or indistinct margins,
heterogenous echogenicity,
intranodular vascular margins, size over 1 cm
microcalcification, complex cyst patterns
suspect malignancy and should undergo ultrasound guided FNA
75% of solitary nodules show benign lesions
96
FNA of solitary thyroid nodule
75% of solitary nodules show benign lesions
97
solitary thyroid nodule found to be benign- tx?
T4 replacement is shown to decrease nodule size by 20%
98
what if the benign solitary thyroid nodule has no response to T4 therapy and the pt is euthyroid
discontinue
99
thyroid cancer
- gender
- prognosis
women 3:1
prognosis is worse in men
9% fatal
100
thyroid cancer could have hyper or hypothyroid symptoms
May have hyperthyroid symptoms due to excess T4 production including thyroid storm.
101
painless neck swelling and a palpable, single form nodule
thyroid cancer
102
thyroid cancer- diagnostic test
- RAIU to do what
- other test that is useful
- FNA diagnostic
- RAIU helpful to assess risk of malignancy and help plan surgical approach
- PET for detecting thyroid cancer mets with limited iodine uptake
- U/S to determine size and location as well as neck metastasis
103
thyroid cancer blood work
T4 normal except for Follicular cancer which produces T4
TSH normal except for Follicular cancer were the excess T4 will suppress TSH
There are tumor markers like serum carcinoembryonic antigen, calcitonin and serum thyroglobulin which can be followed.
104
thyroid cancer mets where? get what tests?
CT – for metastasis especially lung
MRI – for metastasis especially bone
U/S to determine size and location as well as neck metastasis
105
thyroid cancer tx
- Total or near total thyroidectomy
| - Neck dissection and lymph node removal if indicated
106
thyroid cancer post op thyroidectomy tx
- Levothyroxine (synthetic T4) immediately post op for thyroidectomy patients
- Radioactive iodine ablation is used postoperatively for residual disease, metastatic disease and to prevent recurrence.
- Patients should receive whole body radioactive iodine scans. Remission is defined as two successive negative scans
107
medullary cancer thyroid cancer pts
Those with medullary cancer should have family members get a genetic work up and thyroid surveillance
108
Radioactive iodine ablation for brain mets
It should be noted that this is ineffective with mets to the brain which must be removed surgically with gamma knife
109
- childhood irradiation to head and neck
| - FH, gardner syndrome, MEN type II syndrome
- confers a 25 fold increase in thyroid cancer and may emerge 10-40 post exposure
- other risk factors for thyroid cancer
110
thyroid cancer
- most common
- MEN
- most aggressive
- least aggressive
- most common is papillary
- MEN is Medullary
- most aggressive is anaplastic
- least aggressive is papillary
111
thyroid cancer
- early mets
- lymphatic spread
- slow growing
- rapidly enlarges
- early mets is medullary
- lymphatic spread- papillary
- slow growing- papillary
- rapidly enlarges- anaplastic
112
thyroid cancer
- good prognosis
- found in older pts
- may cause thyroid storm
- childhood head/neck radiation
- good prognosis is papillary and follicular
- found in older pts is anaplastic
- may cause thyroid storm is follicular
- childhood head/neck radiation is at risk for papillary
113
thyroid cancer
- found in calcitonin producing C cells
- often causing dysphagia or vocal cord paralysis
- often mets to lung, brain, bone, liver
- rapidly enlarges and early mets to local and distant sites
- found in calcitonin producing C cells is medullary
- often causing dysphagia or vocal cord paralysis is anaplastic
- often mets to lung, brain, bone, liver is follicular
- rapidly enlarges and early mets to local and distant sites is anaplastic
