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68 Cards in this Set
- Front
- Back
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most common cause of hypothyroidism
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Autoimmune thyroiditis (Hashimoto's disease)
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Common causes of hypothyroidism (4)
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1) Autoimmune thyroiditis
2) Following tx for hyperthyroidism 3) Idiopathic 4) Iodine deficiency (rare in US) |
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Symptoms of hypothyroidism
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Weakness, sleepiness, mental slowness, muscle aches, cold intolerance, hoarseness, weight gain, constipation, decreased sweating, menorrhagia
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Signs of hypothyroidism
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Dry, cool skin
Puffy eyelids and face Alopecia, coarse brittle hair Thick tongue, slow speech Bradycardia Swelling of hands and feet Memory impairment Delayed DTR relaxation Slow movements |
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What is myxedema?
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Accumulation of hydrophilic mucopolysaccharides in subcutaneous tissues, found in severe cases of hypothyroidism.
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most sensitive test for diagnosis of primary hypothyroidism
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TSH
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Secondary or tertiary hypothyroidism: what are the causes?
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TSH or TRH deficiency, respectively
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How to dx Secondary or tertiary hypothyroidism?
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Free T4 levels.
(TSH or TRH will be low) |
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Appropriate therapy for hypothyroidism in overwhelming majority of patients is __________
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levothyroxine (T4)
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T/F The dose of thyroxine needed to maintain euthyroid in pregnancy may be increased 25-50%
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T
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The replacement dose to lower serum TSH into the normal range is significantly (Less, More) in older patients than younger.
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Less
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Cretinism: defn
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neonatal hypothyroidism
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Clinical features of cretinism
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mental retardation, short stature, puffiness of face and hands
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Juvenile/childhood hypothyroidism refers to hypothyroidism occurring before age ____
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3
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T/F Juvenile/childhood hypothyroidism causes mental retardation
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F. After age 3, dependence of brain on TH wanes, so it's rarely associated with permanent mental retardation.
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End stage of untreated hypothyroidism
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Myxedema coma
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Myxedema coma: characteristics
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progressive weakness, altered mental status, hypothermia, hypoventilation, hypotension, hypoglycemia, hyponatremia
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Myxedema coma: typical patients
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elderly women with longstanding hypothyroidism.
May have precipitating factors ilke CVA, CHF, infections, prolonged cold exposure, superimposed medical illness. |
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diverse group of inflammatory conditions affecting the thyroid gland, ranging from acute bacterial infection to chronic autoimmune disease
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Thyroiditis
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4 categories of thyroiditis
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1) Acute
2) Subacute granulomatous 3) Subacute lymphocytic 4) Invasive fibrous |
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Acute Suppurative Thyroiditis: characteristics and clinical signs
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Rare
Bacterial and fungal Fever, sweats, tachycardia, pain and tenerness in lower neck Leukocytosis |
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Subacute Granulomatous (deQuervains) thyroiditis: characteristics
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not uncommon, probably viral
Causes anterior neck pain radiating to ears, malaise, fever Thyroid is moderately enlarged, tender, assymetrics. Signs and sx of mild hyperthyroidism. |
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Tx od Subacute Granulomatous (deQuervains) thyroiditis
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ASA, prednisone in severe cases, beta blockers for hyperthyroidism
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Subacute Granulomatous (deQuervains) thyroiditis: how do thyroid fxn tests change?
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1/2 patients have elevated TFTs, decreased RAI uptake.
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Subacute Granulomatous (deQuervains) thyroiditis:phases
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Clinical course: 2-6 months with occasional recurrences
Phases: Hyperthyroid (50%) Euthyroid Hypothyroid (25%) Recovery (<5% become permanently hypothyroid) |
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Subacute Lymphocytic (Painless) Thyroiditis: clinical characteristics
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Unknown etiology
See mild hyperthyroidism. Thyroid is mildly-moderately enlarged, firm, NON TENDER. |
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Subacute Lymphocytic (Painless) Thyroiditis: how do thyroid fxn tests change?
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Elevated TFTs, low RAI uptake, then spontaneous resoltuion
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Subacute Lymphocytic (Painless) Thyroiditis: tx
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beta blockers for hyperthyroidism symptoms
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Subacute Lymphocytic (Painless) Thyroiditis: unusual features
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occurs commonly in postpartum period, persistent goiter and hypothyroidism more common after granulomatous thyroiditis, recurrent thyroiditis is common in postpartum period
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Invasive Fibrous (Riedel’s Thyroiditis): clinical characteristics
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v rare
presents as stony hard, nontender mass, fixed to surrounding structures, may cause tracheal narrowing |
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Invasive Fibrous (Riedel’s Thyroiditis): change in thyroid fxn tests
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None - normal TFTs
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Invasive Fibrous (Riedel’s Thyroiditis): tx
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surgery, corticosteroids, tamoxifen
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Chronic Lymphocytic (Hashimoto’s, Autoimmune) thyroiditis: clinical characteristics
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Common
Presents as firm diffuse goiter with or without hypothyroidism. |
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Chronic Lymphocytic (Hashimoto’s, Autoimmune) thyroiditis: change in TFTs
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varies, but usually normal or hypothyroid
Serum have anti thyroglobulin and anti thyroid peroxidase (TPO) antibodies |
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Chronic Lymphocytic (Hashimoto’s, Autoimmune) thyroiditis: how to diagnose
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look for the antibodies
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Chronic Lymphocytic (Hashimoto’s, Autoimmune) thyroiditis: tx
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thyroxine for hypothyroidism and goiter suppression, rarely surgery for large goiters
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Differential dx of painful anterior neck mass
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1) Subacute granulomatous thyroiditis
2) Hemorrhage into preexisting thyroid lesion 3) Acute suppurative thyroiditis 4) Rapidly enlarging thyroid malignancy 5) Painful Hashimoto's thyroiditis 6) Nonthyroid disorders: infected thyroglossal duct cyst |
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Focal or Diffuse Thyroid Enlargement
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Goiter
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T/F Patients with goiters may be euthyroid, hypothyroid, or hyperthyroid
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T
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single palpable mass in otherwise normal gland
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solitary nodule
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enlarged gland with two or more discrete nodules
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multinodular goiter
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What is a toxic goiter?
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Producing excessive thyroid hormones (causing hyperthyroidism)
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What is the pathogenesis of goiter?
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1) TSH stimulation (due to ineffective TH synthesis)
2) Neoplasia: benign or malignant 3) Genetic factors |
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Most common of all thyroid disorders
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Goiter
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T/F Women are affected with goiter 5-6x more frequently than men
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T
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Clinical presentation of goiter
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1) Symptoms of hyper or hypothyroidism
2) Asymptomatic thyroid enlargement 3) Sensation of fullness or tightness in neck 4) Dysphagia |
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Hoarseness with a goiter suggets what?
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Thyroid malignancy
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Diagnostic evaluation/work up of goiter
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1) Careful history and PE
2) TFTs 3) Thyroid antibody studies for suspected Hashimoto's disease 4) Bx of appropriate nodules 5) Imaging studies: radioiodine scanning, ultrasonography, neck CT or MRI |
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Tx of Euthyroid Goiter
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Observation
Thyroid hormone suppression Radioactiveiodine ablation Sx |
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Tx of Goiter with hypothyroidism
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Thyroid hormone - levothyroxine
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Tx of Toxic Goiter (hyperthyroidism)
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Radioactive iodine
Antithyroid drugs Surgery Symptomatic tx (beta-blocker) |
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T/F Goal of work-up should be to select only those patients at significant risk of cancer for thyroid surgery
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T
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T/F Thyroid nodules and cancer are common
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F. Nodules are common, but cancer is rare, and death from thyroid cancer is even more rare.
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Differential dx of thyroid nodule
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Multinodular goiter
Lymphocytic thyroiditis Benign adenoma (usually follicular) Colloid nodule Cyst Carcinoma |
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Factors in history suggesting thyroid malignancy
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Age <20 or >60
Male gender History of neck radiation Recent change in size of nodule Hoarseness, dysphagia Family h/o medullary or papillary thyroid cancer, MEN 2 |
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Factors in PE suggesting thyroid malignancy
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Hardness
Fixation to surrounding tissues Cervical adenopathy Vocal cord paralysis Distant metastases |
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T/F Patients with multiple nodules have increased risk of malignancy as compared to solitary nodules
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F
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What lab studies should be done to work up a thyroid nodule?
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1) TFTs - especially serum TSH
2) If TSH is suppressed, proceed to RAI scan to look for "hot" nodule 3) If TSH is normal or high, proceed to thyroid ultrasound 4) Fine needle aspiration bx 5) If suspicious, do a thyroid scan. 6) Cold thyroid scan -> surgery. Hot thyroid scan ->Observe |
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T/F RAI scan should not be part of the initial evaluation of patients with a normal TSH
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T
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What info does a thyroid US provide?
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Distinguishes cystic, solid, and mixed lesions
(not really a way to distinguish benign vs. malignant) |
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Fine needle aspiration biopsies are usually done under guidance of what?
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Ultrasound
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Fine needle aspiration biopsies: Pros
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Safe
Inexpensive Accurate |
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Fine needle aspiration biopsies: Cons
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Inadequate specimens
Need experienced cytologist Suspicious (indeterminate) biopsies Rare hematomas |
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What are options for a benign Fine needle aspiration biopsy?
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Can suppress with T4 (drug). Aim for TSH in low normal range.
Observe - serial ultrasounds If stable, no intervention. If it grows, rebiopsy or do surgery. |
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For routine thyroid nodules, is thyroxine recommended?
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No
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Presence of ____ mutation in specimen is diagnostic of an underlying malignancy
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BRAF
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What are the differentiated thyroid cancers? Which is more common?
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Papillary (65%)
Follicular (20%) |
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What are the undifferentiated thyroid cancers?
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Medullary
Anaplastic Lymphoma |
