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69 Cards in this Set

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(3) causes of Macroglossia
Acromegaly;

Myxedema;

Amyloidosis
Definition:
Increased synthesis and secretion of free thyroid hormones resulting in hypermetabolism
Hyperthyroidism
Etiology of Hyperthyroidism
(4)
Grave's Dz;

Toxic Nodular Goiter;

Plummer's Dz (toxic adenoma);

Subacute thyroiditis
Dx:
heat intolerance, sweating, palpitations, weight loss, tremor, nervousness, weakness, hyperdefication
Hyperthyroidism
When is the only time TSH is increased and TRH is decreased?
Pituitary tumor (secretes TSH)
When is the only time TSH and TRH are both increased (w/ T3 and T4 decreased)?
Primary Hypothyroidism
Definition:
A medical emergency consisting of an exaggerated manifestation of hyperthyroidism
Thyroid Storm
Etiology of a Thyroid Storm
(4)
1. Trauma, infection;

2. DKA;

3. MI, CVA, PE;

4. Withdrawl from anti-hyperthyroid meds
Dx:
fever, tachycardia, high-output CHF and volume depletion, exhaustion, diarrhea, abdominal pain, agitation and confusion, possible jaundice
Thyroid Storm
What is the BP change w/ hyperthyroidism?
Isolated systolic HTN
(4) Primary stabilization Tx for a Thyroid Storm
Airway protection;

Oxygenation;

Assess circulation and BP;

IV hydration
Aside from primary stabilization, how is a Thyroid Storm treated?
(4 together)
1. Beta-blocker - block adrenergic effects;

2. Acetaminophen - fever;

3. PTU - block new thyroid hormones

4. Iodine - 1.5 hrs after PTU to decrease release of preformed thyroid hormones
Definition:
Autoimmune Dz causing hyperthyroidism due to Ab, which stimulates TSH receptor
Graves Dz
Dx:
diffusely enlarged thyroid, exopthalamos, pretibial myxedema, tachycardia
Graves Dz
Dx tests for Graves Dz
(4)
1. High radioactive iodine uptake
(if present but low, then Dx is thyroiditis)

2. high Free thyroid hormones;

3. Undetectable TSH levels;

4. High thyroglobulin levels
what is the Long-term anti-thyroid therapy?

complication?
PTU

complication:
Leukopenia
what is the preferred Tx for Graves Dz?

AE?
Radioactive Iodine Ablation Therapy

AE:
can result in Hypothyroidism over time
what should be used as adjunctive therapy for Graves Dz?
Adrenergic Antagonist:

Propranolol
Definition:
TSH levels are more then twice the upper limit of normal
Hypothyroidism
Etiology of Primary Hypothyroidism
(5)
Hashimoto's thyroiditis;

Radiation to neck;

Subacute thyroiditis;

Iodine deficiency (or excess);

Medications: Lithium
Etiology of Secondary Hypothyroidism
(3)
Secondary = Pituitary problem:

Sheehan's syndrome;

Pituitary neoplasm;

Infiltrating Dz (TB) causing TSH deficiency
Etiology of Tertiary Hypothyroidism
(3)
Tertiary = Hypothalamic problem:

Granuloma;

Neoplasm;

Radiation
Dx:
fatigue, lethargy, weakness, weight gain, constipation, cold intolerance, slow speech, dry skin, brittle hair, delayed deep tendon reflexes
Hypothyroidism
Because muscle weakness and cramps are associated w/ both hyper and hypothyroidism, how can you tell the difference w/ CPK level?
Hyper: CPK is normal


Hypo: CPK is elevated
what additional lab tests may be elevated or decreased w/ hypothyroidism?
(4 categories)
Increased:
1. Cholesterol and TG

2. LFTs: LDH, AST, ALT, MM of CPK

Decreased:
3. Hct and Hb

4. serum sodium
If a patient presents w/ high cholesterol, what should you consider testing?
thyroid function tests

(since high cholesterol is a sign of hypothyroidism)
what test is useful from distinguishing secondary from tertiary hypothyroidism?
what are the results of each?
TRH stimulation test:

Secondary: Low

Tertiary: normal
Tx for Hypothyroidism

How often do you check meds?

How is therapy monitored (b/t primary and secondary hypothyroidism)?
Low-dose Levothyroxine
(increase dose every 6 to 8 weeks, depending on patient's response)

Primary: measure TSH levels

Secondary: measure T-4 levels
Definition:
elevated TSH w/ normal thyroid hormone levels in the absence of overt clinical symptoms

what are the (2) possible prognosis?
Subclinical Hypothyroidism

1. can become Primary Hypothyroidism

2. become Euthyroid
Tx parameters for replacement therapy for Subacute Hypothyroidism
(3)
1. All patients w/ TSH > 10

2. Patients w/ TSH > 5 and Goiter or Anti-thyroid Ab

3. All patients w/ Hx of Iodine therapy
(2) Antibody tests that are positive in Hashimoto's thyroiditis
Anti-thyroglobulin


Anti-microsomal
Definition:
Life-threatening complication of Hypothyroidism w/ profound lethargy or worse, usually assoc. w/ hypothermia
Myxedema Coma
Etiology of Myxedema coma
(4)
Sepsis;

Prolonged exposure to cold weather;

CNS depressants;

Trauma/surgery
Dx:
hypothermia w/ rectal temp < 95; bradycardia or circulatory collapse; severe lethargy; delayed relaxation of DTR or Areflexia
Myxedema Coma
Tx for Myxedema coma (in order)
(5)
1. Airway management
2. Prevent further heat loss
3. Glucocorticoids
4. IV Levothyroxine
5. IV hydration (D5 1/2 NS)
Why are glucocorticoids given before levothyroxine in the Myxedema patient?
due to the concern that the patient may have associated Addison's Dz. Giving only thyroxine could initiate an Addisonian crisis
In Hashimoto's Thyroiditis, what destroys the thyroid?
CD-4 lymphocytes
What PE finding distinguishes Hashimoto's from other forms of Thyroiditis?
Thyroid is not tender
Etiology of Thyroiditis types:
1. Subacute
2. Silent
3. Suppurative
4. Riedel's
1. Subacute: Post-viral (usu a UTI)

2. Silent: Postpartum (autoimmune)

3. Suppurative: Bacterial or fungal
(commonly seen w/ PCP in HIV pt)

4. Riedel's: Fibrous infiltration of unknown etiology
Dx:
35-yo female w/ Hx of hyperthyroidism and recent flu presents w/ neck pain and elevated ESR
Subacute Thyroiditis
Dx:
tender, enlarged thyroid, fever and signs of hyperthyroidism; jaw or tooth pain; hypothyroidism may develop

what other Dx is similar to this w/o tenderness?
Subacute Thyroiditis


other: Silent thyroiditis
Dx:
fever w/ severe neck pain, focal tenderness of involved portion of thyroid
Suppurative Thyroiditis
Dx:
slowly enlarging rock hard mass in anterior neck, tight and stiff neck, fibrosis of mediastinum
Riedel's Thyroiditis
what labs allow you to distinguish b/t Subacute, Silent and suppurative thyroiditis?
Silent:
high serum Thyroglobulin levels only
(and possible Antimicrosomal Ab)

Subacute:
high serum Thyroglobulin levels and WBC left shift

Suppurative:
WBC w/ left shift only
What is Tx for:
1. Pain from Subacute thyroiditis

2. Suppurative thyroiditis

what should never be given to any thyroiditis patient?
1. NSAIDs (or steroids)

2. IV Abx and drainage of abscess

Never give PTU to thyroiditis
*Best test to evaluate a thyroid nodule
Fine-needle aspiration
If thyroglobulin levels return to normal after a thyroidectomy, what does that suggest?
Absence of metastatic thyroid tissue
what test distinguishes b/t Hot and Cold thyroid nodules?

what is the difference b/t them?

which is more likely malignant?
Thyroid Scan w/ t-99

Hot:
Hyperfunctioning thyroid; less likely malignancy

Cold:
Hypofunctioning thyroid; more likely malignant
(4) Types of thyroid Cancer

which is most common?
has best prognosis?
worst prognosis (0% survival in 5 yrs)?
Seen in MEN II and III?
1. Papillary - MC; best prognosis

2. Follicular

3. Anaplastic - worst prognosis

4. Parafollicular (Medullary) - in MEN II and III
Thyroid CA:
ground-glass "Orphan Annie" nuclei and psammoma bodies
Papillary
Thyroid CA:
good prognosis but commonly bloodborne mets to bone and lungs
Follicular
Thyroid CA:
cancer of the "C" cells, derived from branchial pouch 5 and secretes Calcitonin
(2 names)
Parafollicular

(Medullary thyroid CA)
Tx for any thyroid CA
(2)
Thyroidectomy

Oral thyroxine supplements after surgery
Definition:
hypersecretion of PTH by the parathyroid gland
Primary Hyperparathyroidism
Definition:
Glandular hyperplasia and elevated PTH in an inappropriate response to hypocalcemia
Secondary Hyperparathyroidism
Definition:
continued elevation of PTH after the disturbance causing secondary hyperparathyroidism has been corrected
Tertiary Hyperparathyroidism
Etiology of Hyperparathyroidism
(3)
Hyperplasia of all 4 glands;

Adenoma/carcinoma;

MEN II and III
Pathophysiology of the parathyroid gland
(4 ways to increase Calcium)
PTH increases serum Ca levels:

1. stimulates renal hydroxylation of Vit-D
(needed for GI to absorb Ca)
2. Increases renal resorption of Ca
3. Decreases renal resorption of phosphorus;
4. Increases Osteoclastic resorption of bone
(via osteoblast receptors)
what do lab tests show to Dx Hyperparathyroidism?
(3)
high serum calcium (low phos);

high serum PTH;

hypercalciuria
what are the indications for surgery w/ Dx of hyperparathyroidism?
(2)
Adenomas should be removed;

Hyperplasia of all four glands: remove and reinsert a small portion of one on the SCM so that it is accessable if problems arise
Emergent measures taken (PRN) w/ hyperparathyroidism
(3)
1. Hydration w/ Lasix

2. Bisphosphonates to block bone resorption

3. Calcitonin
When is Mg deficiency seen?
(3)
SAP:

SIADH;

Alcoholism;

Pancreatitis
SAP
Etiology of Hypoparathyroidism
(3)*
HID Parathyroids:

Hypomagnesium;

Infiltrative CA / Irradiation;

DiGeorge Syndrome;

Post-surgical
HID Parathyroids
Dx:
30-yo woman presents w/ perioral paresthesia and long QT interval. She recently had surgery on her goiter.
Hypoparathyroidism
Dx:
seizures, perioral paresthesia, tetany, fasciculations, muscle weakness, CNS depression, faint heart sounds, bronchospasm
Hypoparathyroidism
What is seen in hypoparathyroidism on the EKG?
QT prolongation
Tx for hypoparathyroidism
(life-threatening versus maintenance)
Life-threatening:
IV Calcium

Maintenance:
Calcitriol and oral calcium
Dx:
Similar characteristics to Hypoparathyroidism, but tissue is resistant to PTH, causing an INCREASE in serum PTH
Pseudohypoparathyroidism
What is pseudohypoparathyroidism assoc with?
Albright's hereditary osteodystrophy