Einstein 11-02-07 Thyroid Diseases And Disorders

Front 1

If target hormone is low,
normally, the pit hormone is ___

Back 1

high

Front 2

If target hormone is low,
and the pit hormone is low (abnormal),
and HT hormone is high,

a) secondary disorder
b) tertiary disorder

Back 2

a) secondary

Front 3

If target hormone is low,
and the pit hormone is low (abnormal),
and HT hormone is low,

a) secondary disorder
b) tertiary disorder

Back 3

b) tertiary disorder

Front 4

To screen for hypothyroidism, which hormone do you measure?

Back 4

TSH

actually, "sensitive TSH", sTSH
Not great, but the better compared to T4

Front 5

Which is more active in wt metabolism and energy?

a) T3
b) T4

Back 5

T3

Front 6

How is T3 made active in the body?

a) cyclically
b) continuously
c) when it is needed

Back 6

a) cyclically

Front 7

If pt is tired and gaining wt
and TSH and T4 are normal, what may be causing the problem?

Back 7

Failed T3 conversion from T4

maybe an enzyme problem.

Front 8

T4

a) prohormone
b) active hormone

Back 8

a) prohormone

Front 9

What's the reason for hypothyroidism of pregnancy?

Back 9

Increase in TBG sucks up free T4 and T3

Front 10

Fraction of total T4 that is unbound (free)?

Back 10

0.0003

Front 11

TSH release is due to the level of

a) free T4
b) T4
c) Free T3
d) T3
e) both free T4 and T3

Back 11

a) free T4

Front 12

If sTSH is high,
what do you do?

Back 12

measure free T4

Front 13

If sTSH is high,
and free T4 is low,
what do you know?

Back 13

primary hypothyroidism

Front 14

If sTSH is high, and free T4 is NORMAL, what do you know?

Back 14

insipient hypothyroidsim,

do a TRH test to confirm.
If TRH is low, then pt is on the way to primary hypothyroidism

If TRh is high, then pt may have a HT problem

Front 15

If sTSH is high,
and free T4 is high,
what do you know?

Back 15

pituitary hypothyroidism

Front 16

If sTSH is low,
What do you do?

Back 16

measure free T4

Front 17

If sTSH is low,
and free T4 is high,
what do you know?

Back 17

thyrotoxicosis

Front 18

If pt has thyrotoxicosis, what do yo do next?

Back 18

RAIU

Front 19

If sTSH is low,
and free T4 is low,
what do you have?

Back 19

pituitary hypothyroidism

Front 20

If sTSH is low,
and free T4 is normal,
what do you know?

Back 20

maybe insipient hypothyroidism.

measure TRH to confirm

Front 21

Test that differentiates non-pituitary THYROTOXIC states

Back 21

RAIU (I^123)

Front 22

Test that is useful for NODULAR disease only, HOT/COLD nodules

Back 22

Thyroid Scan (scintiscan or radionuclide)
(Tc^99m)

Front 23

Test that determines/follows SIZE of nodules, Cystic/Solid


(BOARDS< BOARDS< BOARDS)

Back 23

Thyroid Ultrasound

Front 24

Give IV TRH dose,
what do you expect?

Back 24

TSH to rise.

Front 25

If you give IV TRH, and TSH does not rise, what do you do then?

Back 25

MRI the pituitary

Front 26

Test that is useful in differentiating Non-pituitary thyrotoxic states(low sTSH, hi FT4)

Back 26

Radioiodine Uptake(RAIU)

Front 27

If you see "hypothyroidism" anywhere in a test question, what test should you NOT think about at all?

Back 27

RAIU

Front 28

Does RAIU have any use in hypothyroidism?

Back 28

no

Front 29

What iodine is used for RAIU?

Back 29

I^123

Front 30

If RAIU is increased what could it be?

Back 30

Graves’ disease
HOT NODULES:
Multinodular goiter
Toxic solitary Nodule
hCG secreting tumor

Front 31

If RAIU is decreased what could it be?

Back 31

Self Limited Thyroiditis-Induced Thyrotoxic states:
Painless thyroiditis
Subacute thyroiditis
Postpartum thyroiditis

Front 32

Thyroid Scan AKA

Back 32

'scintiscan’ or a ‘radionuclide’ scan

Front 33

scintiscan is only used for what?

Back 33

NODULAR DISEASE

Front 34

thyroid scan uses what contrast media?

Back 34

Tc^99m

Front 35

The BEST way to determine if a nodule is HOT or COLD.

Back 35

radionuclide scan

Front 36

RAIU produces a

a) number
b) picture

Back 36

a) number

Front 37

scintiscan produces a

a)number
b) picture

Back 37

b) picture

Front 38

Test that is Useful for determining:
1. Whether a Nodule is CYSTIC or SOLID.
2. SIZE of Nodules

Back 38

Thyroid Ultrasound

Front 39

FACTS about Thyroid Nodules

5-10% of all Nodules are

a) BENIGN
b) MALIGNANT

Back 39

b) MALIGNANT

Front 40

FACTS about Thyroid Nodules

Virtually all HOT or CYSTIC nodules are

a) BENIGN
b) MALIGNANT

Back 40

a) BENIGN

Front 41

FACTS about Thyroid Nodules

95% of SOLITARY nodules are

a) HOT
b) COLD

Back 41

b) COLD

Front 42

85% of SOLITARY nodules are COLD and

a) BENIGN
b) MALIGNANT

Back 42

a) BENIGN

Front 43

5% of patients who had neck radiation as a child will develop malignant nodules(______ carcinoma).

a) medullary
b) papillary
c) follicular

Back 43

b) papillary

Front 44

So, you did a US and found a SOLITARY nodule. What do you do next?

Back 44

FNA

EXCEPT if Thyrotoxic, then do a SCINTISCAN(Tc)

Front 45

What do you expect to find?

Back 45

a cold nodule

Front 46

With MULTIPLE nodules, ALWAYS think of what?

Back 46

HASHIMOTO-
Thyroiditis

Front 47

What do you do if your pt has multiple nodules?

Back 47

do blood for AntiMicrosomal Antibodies.

Front 48

The benign thyroid tumor AKA

Back 48

adenoma

Front 49

the malignant thyroid tumor AKA

Back 49

carcinoma

Front 50

Most thyroid adenomas are

a) follicular
b) medullary

Back 50

a) follicular

Front 51

BENIGN-Thyroid ‘Adenoma’

most are
a) single
b) multiple

Back 51

a) single

Front 52

benign thyroid adenoma

Most are
a) HYPER-functioning
b) HYPO-functioning

Back 52

a) HYPER-functioning (ie.produces thyroxine)
& grow slowly. They start WARM & become HOT.
(Remember, HOT nodules are Benign)

Front 53

BENIGN-Thyroid ‘Adenoma’

Treatment for HYPERthyroid patients:
a) radioactive I^131
b) Surgery
c) both
d) either / or

Back 53

either radioactive I^131 or Surgery.

Front 54

MALIGNANT-Thyroid ‘Carcinoma’

2 types

Back 54

1. Parafollicular cancer - called Medullary Thyroid Cancer

2. Follicular cancer - 3 histiologic types

Front 55

Parafollicular malignant thyroid carcinoma affects what cells

Back 55

parafollicular C-cells

Front 56

Parafollicular Type (medullary) thyroid carcinoma affects the C cells and therefore increases what hormone production?

Back 56

calcitonin

Front 57

Parafollicular Type thyroid carcinoma

15% occur in MEN II (2A) and MEN III (2B)
so, MUST check ______

Back 57

FAMILY HISTORY!!!

Front 58

Most Common MALIGNANT-Thyroid Carcinoma

Back 58

Papillary carcinoma


(Follicular Type)

Front 59

Pt has thyroid mass & distant metastasis.

Think what type of thyroid cancer?

Back 59

Follicular carcinoma


early ‘hematogenous spread’ to bone and lung(s).

Front 60

what type of thyroid carcinoma?

Rare, but Highly MALIGNANT
present: rapidly growing mass

Back 60

Anaplastic carcinoma

Front 61

The best way to treat thyroid carcinoma?

Back 61

take it out

Front 62

If pt had thyroid carcinoma taken out,

If TSH is > 50 mU/L (profoundly hypothyroid), what do you do?

Back 62

do total body thyroid scan to look for distant HOT nodules

Front 63

What if you find distant hot nodules?

Back 63

then give high dose
Radioactive Iodine Treatment (the “BOLT”)

Front 64

What if you don't find distant hot nodules?

Back 64

If NORMAL, then add T4(Thyroxine) until TSH returns to Normal

Front 65

If a woman is amenorrheic and has elevated prolactin level, then
CHECK for what?

Back 65

HYPO-Thyroidism. If she is EU-Thyroid, then look for a prolactinoma.

Front 66

IF, sTSH is LOW ‘AND’ FT4 is LOW too,
then it is ______

Back 66

HYPOTHALAMIC HYPOTHYROIDISM (RARE).

Front 67

In Hypothalamic Hypothyroidism, then there is ALWAYS a deficiency of the OTHER ‘Pituitary’ hormones. MUST CHECK what?

Back 67

serum cortisol or 24hr urine 17-hydroxy corticosteroids

Front 68

Hypothyroidism Treatment

GENERAL RULE

Back 68

Replace with Levothyroxine (T4)

Front 69

When does your hypothyroid pt have the RTC (return to clinic)?

Back 69

recheck sTSH in 4-6 weeks before adjusting.

Front 70

Symptoms of hypothyroidism

Back 70

cold intolerence, apathy/depression, hair loss, myxedema,
CHF, loss of menstruation in woman (amenorrhea), etc.

Front 71

Lab findings of hypothyroidism

(pit hormones and sodium level)

Back 71

HI prolactin levels, HYPO-Natremia (low sodium

Front 72

Shoul you treat the Pregnant Hypothyroid patient?

Back 72

ALWAYS treat the Pregnant Hypothyroid patient.

Front 73

MOST COMMON causes of hyperthyroidism are:

Back 73

Graves and Lymphocytic thyroiditis

Front 74

Problematic antibodies of Graves disease

Back 74

IgG

Front 75

TRIAD of signs for Graves Disease:

Back 75

1. 70% have Diffuse, Soft and Symmetric Goiter
2. Opthalmopathy- including:
i) lid lag and lid retraction due to sympathetic over-stimulation (it REVERSES with treatment) ii) exopthalmus-which is not understood and not necessarily-reversible, even with treatment.
3. Pretibial Myxedema- thickened and reddened dermis due to a lymphocytic infiltrate. Peau d’orange appearance to the skin.

Front 76

Onycholysis-very Specific for Graves disease, yet only
see in 10% of Graves.
its when the nail separates from the nail bed.

Back 76

Onycholysis

Front 77

elderly Graves patients who frequently present with ATYPICAL presentations including:
Apathy, Weight Loss, Atrial Fibrillation, CHF, Constipation.
They present as depressed or PMR (polymyalgia rheumatica…)

Back 77

APATHETIC HYPERthyroidism-

Front 78

ALWAYS evaluate new onset of Fibrillation or CHF in elderly for what?.

Back 78

Hyperthyroidism

Front 79

Graves Treatment

Back 79

OPTIONS are:
1. PTU (propthiouracil)
2. Methimazole (qd) -
3. Surgery-Subtotal Thyroidectomy (ie: spare Parathyroids)