Adult Health Thyroid And Parathyroid

Front 1

function of the parathyroid

Back 1

regulates serum calcium levels
(8.5mg- 10.5mg/dl)

Control important for:
-conduction of nerve impulses
-muscle contraction

Front 2

what is primary hyperparathyroidism?

Back 2

overproduction of PTH

Front 3

most common etiology of primary hyperparathyroidism?

Back 3

Parathyroid Adenoma (87-93% cases)
-overproduction by 1 gland suppresses production of other 3
-rarely cancerous

Front 4

Secondary Hyperparathyroidism

Back 4

-parathyroid secretes excess PTH in response to low serum calcium levels
-this type of d.o is associated with stage 3 and 4 renal disease

Front 5

Paricalcitrol (Zemplar)

action?
adverse reactions?

Back 5

-vit D receptor activator
-suppresses parathyroid hormone

Adverse reaction:
-allergy, rash, arthritis, vertigo/hypercalcemia, Vit D toxicity

Front 6

Patient Education for Hyperparathyroidism

Back 6

- avoid Vit D supplements
- avoid Aluminum-containing drugs (Maalox)
-monitor serum calcium, phosphorus, PTH levels q2 weeks x3 months, then q 3 months
-watch for digitalis toxicity
-signs of hypercalcemia

Front 7

what are EARLY and LATE signs of hypercalcemia?

Back 7

early: weakness, h/a, somnolence, n/v, dry mouth, constipation, muscle & bone pain & metallic taste

late: anorexia, weight loss, photophobia, rhinorrhea, pruritus, hyperthermia, HTN, arrhythmia, over psychosis and death

Front 8

what are some complications of PHPT (Primary Hyperparathyroidism)?

Back 8

-Kidney stones
-electrolyte disturbances (hypercalcemia and hypophosphatemia)
-Bone pain, tumors, fractures
-Proximal muscle weakness

Front 9

If there are GI disturbances or CNS changes with PHPT, what must be ruled out?

Back 9

Cancer

Front 10

what are the subtle symptoms of Asymptomatic PHPT?

Back 10

-anxiety, mood swings, irritability, apathy
-substantial fatigue, proximal muscle weakness

Front 11

Physical Exam of patients with Asymptomatic PHPT will reveal...

Back 11

- low bone mineral density
- Diabetes (excess PTH and Ca increases insulin insensitivity)
-Metabolic Syndrome (abnormal lipid levels, abnormal body fat distribution, High BMI)

Front 12

Labs for Hyperparathyroidism

Back 12

Serum Ca and PTH levels

Serum Ionized Ca

24 hr urine

Front 13

Management of Hyperparathyroidism

Back 13

Evaluate q 6 months
-serum Ca
-Creatinine
-PTH levels

Monitor for:
-DM and HTN

If levels change significantly or co-morbit conditions develop- surgery should be considered

Front 14

what is the gold standard for displaying the overactive parathyroid prior to surgery?

Back 14

Sestamibi scanning

Front 15

what are the 2 types of parathyroidectomy?

Back 15

Bilateral neck exploration (traditional)

Minimally Invasive Radioguided Technique

Front 16

Management of Osteoporosis

Back 16

Alendronate (Fosamax)- not effective in parathyroid disease, more useful after surgery but not a replacement after gland removal

-low Ca diet not recommended- depravation will lead to high PTH secretion (maintain at least Ca 1000mg/day)

-estrogen can help conserve BMD in postmenopausal women

Front 17

what do thyroid hormones do?

Back 17

Accelerate Metabolism
-increase O2 consumption
(except brain, testes and spleen)
-increase BMR by 60-100%
-increase Carbohydrate consumption
(glucose absorption, glycogenolysis, gluconeogenesis)
-Mobilizes fatty acids
-Degrades proteins faster than they can be synthesized (catabolism)

Front 18

why do we need thyroid hormone?

Back 18

-Enzyme system activation and concentration
-Vitamin and mineral metabolism
-Hormone production, secretion, degradation
-Target organ response to hormones
-Protein synthesis, CHO metabolism, lipid synthesis and degradation.

Front 19

an excess of thyroid hormone can lead to _____ in adults (more commonly in women).

Back 19

osteoporosis

Front 20

describe HPT axis (hypothalamus-pituitary-thyroid axis)

Back 20

- hypothalamus secretes TRH (thyro-tropin releasing hormone)
-TRH stimulates pituitary to release TSH (thyroid stimulating hormone)
-TSH acts directly on thyroid to cause follicular growth, hormone synthesis/secretion, iodide metabolism

Front 21

describe feedback mechanism of the HPT axis

Back 21

-circulating T3/T4 levels regulate TSH by: suppressing TRH secretion & decreasing pituitary sensitivity to TRH

-any slight change in circulating T4 produces rapid and potent changes in TSH

Front 22

TSH <0.10
T4 elevated

Back 22

hyperthyroidism

Front 23

TSH >7
T4 decreased or normal

Back 23

hypothyroidism

Front 24

TSH 0.10-3.0
T4 normal

Back 24

subclinical hyperthyroidism

Front 25

TSH 5-7
T4 normal

Back 25

sublinical hypothyroidism

Front 26

what is oral estrogen's effect on serum TBG and T4?

tamoxifen's effect?

pregnancy's effect?

Back 26

Oral estrogen (HRT and OCPs)
increases TBG by 30-50%
decreases T4 by 20-35%

Tamoxifen
Increase TBG slightly

Pregnancy- by 20 weeks, double non-pregnant TBG levels

Front 27

when would you draw a free T3 level?

Back 27

in a clinical situation where pt has clinical symptoms of hyperthyroidism, low TSH, and normal T4.

*T3 thyrotoxicosis*

Front 28

current standard normal TSH range

Back 28

0.3-5.0 mIU/L

Front 29

who should be screened for thyroid disease?

Back 29

routine screening for women > 50 years old for unsuspected asymptomatic thyroid disease

Front 30

Hypothyroid Symptoms and physical exam findings

Back 30

Fatigue, sleepiness
Weight gain
Cold intolerance
Dry skin
Constipation
Memory/concentration problems
Depression
Menstrual changes
Coarseness or loss of hair
Joint Pain
Muscle Cramps

Goiter or Normal (non-palpable) thyroid
Bradycardia
Edema (mixedema)
Cool, dry skin
Puffy face/hands

Front 31

what is Hashimoto's Thyroiditis?

Back 31

-most common form of hypothyroidism
-autoimmune disorder
-lymphocytes become sensitized to thyroid antigens and form autoantibodies, destroying the gland
-familial, more common in women
-associated with Type1 DM, Pernicious anemia, adrenocortical insu

Front 32

management of hypothyroidism

Back 32

daily T4 (synthetic)-- allows normal conversion to occur at the receptor level

Adults:
1.6ug/kg/ideal body weight initially
75-100ug/day for women
100-150ug/day for men

Elderly: (lower initial doses)
1.5ug/kg/ideal body weight
25-50ug/day x5 weeks
Final dose: 70% of Adult dose

Front 33

TSH response to changes in T4 is slow. After initiation of medication for hypothyroidism, what is the minimum time before you will see changes in levels?

Back 33

3 weeks

Front 34

what are nervous system effects in hypothyroidism?

Back 34

Direct:
-Fatigue
-Sleepiness
-Memory/concentration impairments
-Depression

Indirect: Underactivity of SNS
-Bradycardia
-Delayed relaxation of DTR’s
-Cool, dry skin
-Constipation

Front 35

what are nervous system effects in hyperthyroidism?

Back 35

Direct:
-Hyperexcitability
-Nervousness
-Irritability
-Anxiety
-Poor Sleep

Indirect: Overactivity of SNS
-Tachycardia
-Palpitations
-Sweating
-Diarrhea

Front 36

what are causes of hypothyroidism?

Back 36

-Autoimmune Disease (hashimoto's)
-Destruction of gland w/ radioactive iodine
-Antithyroid medications
-Thyroid surgery
-Amiodarone (also causes hyperthyroidism)
-Lithium

Front 37

what are causes of hyperthyroidism?

Back 37

-Graves Disease (toxic diffuse goiter)
-Subacute thyroiditis
-Postpartum thyroiditis
AKA: “silent”, “painless”
-Acute thyroiditis
-Toxic nodular goiter
-Invasive fibrous thyroiditis

Front 38

Hyperthyroid Symptoms and physical exam findings

Back 38

“Hot”- Increased perspiration
Irritable, Nervous
Difficulty Sleeping
Fatigue
Problem concentrating
Frequent BM
Palpitations
Eye complaints
Decreased flow; Amenorrhea
Infertility

Thyroid gland enlarged
Tachycardia
Irregular Pulse/A-Fib
Resistant to cardioversion
Weight loss
Muscles
Hand Tremor
Proximal weakness
Eye changes

Front 39

what are the triad of symptoms of hyperthyroidism in elderly patients?

Back 39

Weight loss, constipation, anorexia

also consider patients with "failure to thrive"
-weight loss
-new onset A-fib
-unexplained increase in angina or CHF

Front 40

what is Grave's disease?

Back 40

-most common form of hyperthyroidism
- autoimmune disease where the thyroid is overactive, producing an excessive amount of thyroid hormones
-autoantibodies bind to and activate TSH receptor in thyroid gland which increases the synthesis and release of

Front 41

eye symptoms seen in hyperthyroidism

Back 41

-exopthalmos
-gritty, pain, tearing, photophobia, vision that clears with blinking
-diplopia, impaired upward or lateral gaze
-compression of optic nerve- decreased visual acuity, diminished color vision/contrast, visual field defect

Front 42

skin symptoms see in hyperthyroidism

Back 42

dermopothy- lumpy, reddish thickening of the skin, results from a buildup of protein in the skin

-lower leg/dorsum foot non-pitting edema

Front 43

Thyroid storm

Back 43

-Life-threatening exaggeration of hyperthyroidism
-Generally occurs in thyrotoxic patient who becomes acutely ill or stressed

Front 44

Subacute Thyroiditis (Inflammation)

Back 44

-Acute inflammatory condition (post viral) Mumps, Coxsackie, Adenovirus
-Self-limiting - eventually completely resolves

Stages:
1) Inflammation; circulation of excess hormone- May resolve at this point
2) Gland “sick”; Decrease in hormone produc

Front 45

symptoms, physical exam findings, and lab levels for Subacute thyroiditis (inflammation)

Back 45

-Fever, malaise, sore gland (extends to jaw/ears)
-Initially hyperthyroid
-Later, hypothyroid
-tender thyroid gland
-hyperthyroid phase: TSH low, T3 and T4 high, marked elevated ESR
-hypothyroid phase: TSH gradually rises, T3 and T4 low

Front 46

What is the treatment for Subacute thyroiditis (inflammation)?

Back 46

Stage 1
-supportive (ASA, NSAID’s, Prednisone)
-Hyperthyroid symptom relief (Beta-blockers)
-Antithyroid drugs NOT INDICATED

Stage 2
-Monitor TSH levels closely
-Most patients will remain hypothyroid x2-3 weeks and gradually regain normal thyroid function

Front 47

Acute Thyroiditis (Infection)

Back 47

-uncommon
-infectious (bacteria, parasites, fungi)
-symptoms: neck pain, fever, chills, rigors
-labs: high WBCs, NL thyroid levels
-tx: abx & excision/drainage

Front 48

Postpartum Thyroiditis (silent)

Back 48

-Similar to Subacute (without pain)
-Women, Ages 30-40

Treatment
-Generally supportive
-Long-term may be indicated (6% persist)
-Observe for recurrence in subsequent pregnancies

Front 49

Toxic Multi-Nodular Goiter

Back 49

-Usually seen in postmenopausal women with a long history of goiter
-Multiple nodules hypersecrete T3 (usually)

Front 50

Invasive Fibrous Thyroiditis

Back 50

-Replacement of thyroid parenchyma with dense fibrous tissue
-Present with slowly enlarging, hard “woody” gland
-Middle aged/elderly women predominate
-Usually remain Euthyroid
-Surgery only if compression of adjacent structures occurs

Front 51

Medications used to treat hyperthyroidism

Back 51

Methimazole (MMI)

Prophylthiouracil (PTU)

Front 52

Methimazole

Back 52

-med to treat hyperthyroidism
-blocks synthesis of thyroid hormone
-onset 2-4 weeks
-1/2 life of Thyroxin is 7 days, large gland stores
-immunosuppressive effects

Front 53

Prophylthiouracil

Back 53

-med to treat hyperthyroidism
-Follow q3-4 weeks
-monitor TSH and Free T4
-Dose downward by 25-50% if possible
-Gradually withdraw (hope for remission)
-PROBLEM: Agranulocytosis
Sore throat? Fever?

Front 54

Radioactive Iodine

Back 54

-Pregnancy X: absolutely contraindicated
-Concentrates in the thyroid gland
-Emits radiation
-causes inflammation and necrosis
-eventually atrophy and fibrosis
-Common to give suppressive medications first to decrease stored hormone concentrations.

Front 55

what are beta-adrenergic antagonists (inderal) used for in hyperthyroidism?

Back 55

Relief of catecholamine effects:
tachycardia
palpitations
tremor
anxiety
lid lag

Front 56

Subclinical Hypothyroidism

Back 56

TSH 5.1-10.0 mIU/L most common

common in elderly
common in women

Front 57

Risk Factors for Thyroid Cancer

Back 57

Highly suspicious:
Firm nodule, Rapid growth, Fixation to adjacent structure, Vocal cord paralysis, Regional lymphadenopathy, Metastasis to bone/lung, Family history of multiple endocrine neoplasia (esp..Medullary Thyroid cancer)

Moderately suspicious:
Nodule >4cm in diameter and partially cystic, Age <20 or >60,
Male sex/solitary nodule, History of neck radiation