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Endocrine > 377 Hyperthyroidism > Flashcards

377 Hyperthyroidism Flashcards

1
Q

Preferred drug for thyroid storm

A

PTU

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2
Q

Instance PTU is given over methimazole

A

Thyroid storm
Allergy to PTU
First trimester of pregnancy

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3
Q

Adverse effect of PTU which make it less preferred than methimazole

A

Hepatotoxicity

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4
Q

Most common sign of hyperthyroidism

A

Tachycardia

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5
Q

Most common cause of Thyrotoxicosis

A

Graves disease

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6
Q

Thyrotoxicosis vs hyperthyroidism

A

Thyrotoxicosis: state of thyroid hormone excess
Hyperthyroidism: excessive thyroid hormone

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7
Q

Side effects of PTU if taken during pregnancy

A

Cutis aplasia

Choanal atresia

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8
Q

Patient usually presents with painful and enlarged thyroid, sometimes accompanied by fever

A

Subacute/ De Quervains thyroiditis

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9
Q

Dreaded side effect of methimazole

A

Agranulocytosis

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10
Q

Added benefit of using propanolol in hyperthyroidism

A

Prevents peripheral conversion of T3 to T4

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11
Q

Why exopthalmus in Graves disease

A

Deposition of fat around the orbits pushes the eyes

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12
Q

what’s the most serious manifestation of Graves ophthalmopathy

A

compression of the optic nerve

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13
Q

defined as a state of thyroid hormone excess

A

thyrotoxicosis

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14
Q

major etiologies of thyrotoxicosis

A

hyperthyroidism caused by Grave’s disease, toxic multinodular goiter, and toxic adenomas

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15
Q

True or false. Grave’s disease accounts for 60-80% of thyrotoxicosis

A

True.

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16
Q

Accounts for 60-80% of thyrotoxicosis

A

Graves’ disease

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17
Q

minor risk factor for Graves disease and a major risk factor for ophthalmopathy

A

Smoking

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18
Q

True or false. Graves disease may occur during the immune reconstituution phase after highly active antiretroviral therapy (HAART) or alemtuzumab treatment

A

True.

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19
Q

Kinase inhibitor associated with precipitating Graves disease

A

alemtuzumab

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20
Q

True or false. Cytokine play a major role in thyroid assocaited ophthalmopathy

A

True.

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21
Q

commonly seen in elderly patients where features of thryotoxicosis are subtle or masked with patients present mainly with fatigue and weight loss

A

apathetic thyrotoxicosis

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22
Q

signs specific for Graves disease

A

ophthalmopathy and dermopathy

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23
Q

True or false. Thyrotoxicosis is sometimes associated with a form of hypokalemic periodic paralysis

A

True.

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24
Q

True or false. Atrial fibrillation among hyperthyroidism patient is seen in those aging more than 50 yrs

A

True.

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25
Q

Which is more common in patients with hyperthyroidism

A

hypercalciuria is more common

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26
Q

where is the bruit best heard in patients with enlarged thyroid in Graves disease

A

inferolateral margins

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27
Q

what causes lid retraction in patients with hyperthyroidism

A

sympathetic overactivity

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28
Q

earliest manifestations of ophthalmopathy

A

sensation of grittiness, eye discomfort, and excess tearing

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29
Q

how is ptosis best detected

A

visualization of the sclera between the lower border of the iris and the lower eyelid with the eyes in primary position

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30
Q

NO SPECS scoring to evaluate ophthalmopathy

A

0 No signs 1 Only lid retraction 2 Soft tissue involvement 3 Proptosis more than 22 mm 4 EOM involved 5 Corneal involvement 6 Sight loss

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31
Q

Measurement of proptosis in thyroid ophthalmopathy

A

more than 22 mm

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32
Q

thyroid dermopathy occurs in many percent of patients with Graves disease

A

5%

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33
Q

commonly affected area for thyroid dermopathy

A

over the anterior and lateral aspect of the lower leg

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34
Q

name of the thyroid dermopathy that occurs in the legs

A

pretibial myxedema

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35
Q

refers to the noninflamed indurated plaque with a deep pink or purple color and an orange skin appearance

A

pretibial myxedema

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36
Q

refers to form of clubbing that occurs in patients with hypethyroidism

A

thyroid acropachy

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37
Q

incidence of thyroid acropachy

A

1.00%

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38
Q

Evaluation of thyrotoxicosis. TSH low FT4 high. Diagnosis?

A

Primary thyrotoxicosis

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39
Q

Evaluation of thyrotoxicosis. TSH low FT4 high. No features of Graves? Considerations

A

multinodular or toxic adenoma.

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40
Q

Evaluation of thyrotoxicosis. TSH low FT4 high. No features of Graves. Not multinodular goiter. Not toxic adenoma. What to do next?

A

radionuclide uptake

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41
Q

Evaluation of thyrotoxicosis. TSH low FT4 high. No features of Graves. Not multinodular goiter. Not toxic adenoma. Low radioiodine uptake

A

Destructive thyroiditiis, iodine excess, or excess thyroid hormone

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42
Q

Evaluation of thyrotoxicosis. TSH low FT4 high. No features of Graves. Not multinodular goiter. Not toxic adenoma. With radioiodine uptake

A

Rule out other causes including stimulation of choroinic gonadotropin

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43
Q

Evaluation of thyrotoxicosis. TSH low FT4 normal. What to do next?

A

Get FT3

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44
Q

Evaluation of thyrotoxicosis. TSH low FT4 normal. FT3 high.

A

T3 toxicosis

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45
Q

Evaluation of thyrotoxicosis. TSH low FT4 normal. FT3 normal.

A

subclinical thyperthyroidism

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46
Q

what to do with subclinical hyperthyroidism

A

Follow up in 6-12 weeks

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47
Q

Follow up in 6-12 weeks

A

TSH secreting pituitary adenoma or thyroid hormone resistance syndrome

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48
Q

Evaluation of thyrotoxicosis. TSH normal FT4 normal. What to do next?

A

No further tests

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49
Q

How is Graves disease differentiate from destructive thyroiditis, ectopic thyroid tissue, and factitious thyrotoxicosis, toxic adenoma, or toxic MNG

A

High uptake of radionuclide in Graves disease

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50
Q

Differentials of Graves who presents with thyrotoxicosis but without ophthalmopathy or dermopathy

A

destructive thyroiditis, ectopic thyroid tissue, and factitious thyrotoxicosis, toxic adenoma, or toxic MNG

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51
Q

what is the mortality of hyperthyroidism without treatment

A

10-30%

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52
Q

When does thyroid dermopathy develop

A

1-2 years after the development of Graves hyperthyroidism

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53
Q

True or false. Thyroid dermopathy can resolve spontaneous once Graves disease is treated

A

True.

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54
Q

main antithyroid drugs

A

thiomides, PTU, methimazole

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55
Q

What is the action of antithyroid drugs

A

inhibit the function of TPO, reducing oxidation and organification of iodide

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56
Q

Mechanism of action of PTU

A

inhibits the deiodination of T4 to T3

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57
Q

half life of PTU

A

90 mins

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58
Q

half life of methimazole

A

6 hrs

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59
Q

what is the adverse effect of PTU limiting is use in the first trimester of pregnancy

A

hepatotoxicity

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60
Q

what is the initial dose of methimazole

A

10-20 mg BID then once a day dosing once euthyroidism is achieved

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61
Q

what is the dose of PTU

A

100-200 mg q6-8 hrs

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62
Q

when are thyroid function tests reviewed

A

4-6 weeks after starting treatment

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63
Q

True or false. TSH levels often remain suppressed for several months and therefore do not provide a sensitive index of treatment response

A

True.

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64
Q

daily maintenance dose of methimazole

A

2.5 -10 mg OD

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65
Q

daily maintenance dose of PTU

A

50-100 mg OD

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66
Q

what is the block and replace regimen

A

initial dose of antithyroid is held constant and the dose of levothyroxine is adjusted to maintain FT4 in normal levels

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67
Q

types of patients most likely to relapse

A

younger patients, males, smokers and patients with a history of allergy, sever hyperthyroidism, or large goiters

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68
Q

when is maximum remission achieved in 30-60% of patients

A

By 12-18 months

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69
Q

common minor side effects of anti thyroid drugs

A

rash, fever, urticaria, and arthralgia

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70
Q

what to do if with minor side effects

A

change to another antithyroid drug

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71
Q

major side effect of methimazole

A

cholestasis

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72
Q

most important adverse effect of antithyroid drugs

A

agranulocytosis

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73
Q

alternative to propanolol in hyperthyroidism

A

atenolol

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74
Q

dose of propanolol

A

20-40 mg every 6hrs

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75
Q

when should carbimazole to methimazole stopped prior to radioiodine

A

Stopped 2-3 days before radioiodine administration to achieve optimum iodine uptake

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76
Q

when should carbimazole to methimazole resumed after radioiodine

A

re started 3-7 dats after radioiodine

77
Q

true or false. PTU appears to have a prolonged radioprotective effects and should be stopped for a longer period before radioiodine is given

A

True.

78
Q

how long should patients after radioiodine avoid contact or remain in isolation

A

5-7 days to avoid possible transmission of radioisotope

79
Q

what is the usual radioiodine dose

A

370 Mbq (10 mCi) and 555 Mbq (mCi)

80
Q

True or false. Hyperthyroidism can persists for 2-3 months before radioiodine takes full effect

A

True.

81
Q

absolute contraindication to radioiodine

A

pregnancy and breast feeding

82
Q

can be given to prevent exacerbation of ophthalmopathy

A

Prednisone 30 mg/day at the time of radioioidine treatment and tapered over 6-8 weeks

83
Q

given to reduce vascularity of the thyroid gland

A

potassium iodide 1-2 SSKI orally TID for 10 days

84
Q

in pregnant women with hyperthyroidism, until when should PTU be given

A

PTU should be used until 14-16 weeks

85
Q

why PTU in the first trimester of pregnancy

A

due to methimazole carbimazole embryopathy such as cutis aplasia, choanal atresia and tracheoesophageal fistula

86
Q

what is the ratio of PTU to methimazole

A

15-20 mg PTU to 1 mg methimazole

87
Q

heralds neonatal thyrotoxicosis

A

poor intrauterine growth, FHT more than 160 bpm, advanced bone age, fetal goiter and high levels of maternal TSI after 26 weeks gestation

88
Q

True or false. Postpartum is a time for major risk

A

True.

89
Q

presents as a rare life threatening exacerbation of hyperthyroidism accompanied by fever, delirium, seizures

A

thyrotoxic crisis or thyroid storm

90
Q

mortality rate of thyroid storm

A

30%

91
Q

what is the dose of PTU in thyroid storm

A

500-1000 mg loading dose and 250 mg every 4 hours

92
Q

alternative to PTU in thyroid storm

A

Methimazole 20 mg every 6 hours

93
Q

what is the role of propanolol in thyroid storn

A

high doses of propanolol decrease T4 to T3 conversion

94
Q

how to give hydrocortisone in thyroid storm

A

Hydrocortisone 300 mg IV bolus then 100 mg IVTT q8hrs

95
Q

treatment for severe ophthalmpathy

A

pulse therapy with IV methylprednisolone 500 mg of once weekly for 6 weeks then 250 mg once weekly for 6 weeks

96
Q

which is preferred in treatment of opthalmopathy: oral or iv steroid?

A

IV pulse therapy

97
Q

amiodarone treatment is associated with how many percent of thyrotoxicosis

A

10%

98
Q

due to suppurative infection of the thyroid

A

acute thyroiditis

99
Q

most common cause of acute thyroiditis in children and young adults

A

remnant of the piriform sinus

100
Q

other term for subacute thyroiditis

A

de Quervains thyroiditis or granulomatous thyroiditis or viral thyroiditis

101
Q

usual presentation of subacute thyroiditis

A

painful goiter and fever

102
Q

three distinct phases of subacute thryoiditis

A

thyrotoxic phase, hypothyroid phase and recovery phase

103
Q

thyrotoxic phase, hypothyroid phase and recovery phase

A

Aspirin 600 mg every 4-6 hours or NSAIDs

104
Q

in subacute thyroiditis, it no relief with NSAID, what to give next

A

Prednisone 15-40 mg tapered over 6 weeks

105
Q

True or false. In subacute thyroiditis, antithyroid drugs have no role during the thyrotoxic phase

A

True.

106
Q

can levothyroxine be given to subacute thyroiditis

A

yes when hypothyroid phase is prolonged. Low dose levothyroxine 50-100 ug to allow TSH mediated recovery

107
Q

time period of thyrotoxic phase

A

Weeks 1-6

108
Q

time period of hypothyroid phase

A

Weeks 6-12

109
Q

time period of recovery phase

A

Weeks 12-18

110
Q

names of postpartum thyroiditis

A

silent thyroiditis

111
Q

silent thyroiditis, silent thyroiditis

A

thyrotoxicosis for 2-4 weeks followed by hypothyroidism for 4-12 weeks then resolution

112
Q

True or false. Silent thyroiditis is more common in women with type 1 diabetes mellitus

A

True

113
Q

how to differentiate silent thyroiditis form subacute thyroiditis

A

normal ESR and TPO antibodies

114
Q

True or false. Silent thyroiditis patient may develop permanent hypothyroidism

A

True.

115
Q

What is the treatment of silent thyroiditis

A

Propanolol 20-40 mg

116
Q

what drugs can lead to drug induced thyroiditis

A

INF alpha, IL1, tyrosine kinase inhibitors may develop painless thyroiditis

117
Q

True or false. Any acute severe illness can cause abnormalities of circulating TSH or thyroid hormone levels in the absence of underlying thyroid disease

A

True.

118
Q

What is the major cause of these hormonal changes in the thyroid

A

IL 6

119
Q

what is the other name of sick euthyroid sydrome

A

non thyroidal illness

120
Q

what is the hormone pattern in sick euthyroid syndrome

A

decrease in TT3 and FT3, with normal levels of T4 and TSH

121
Q

True or false. The magnitude of the fall in T3 correlated with the severity of the illness

A

True.

122
Q

in acute liver disease, what leads to rise in thyroid hormone

A

rise in total but not free T3 and T4 due to TBG release

123
Q

True or false. Renal disease is often accompanied by low T3 concentrations

A

True.

124
Q

dose of amiodarone associated with very high iodine intake

A

Amiodarone 200 mg per day

125
Q

True or false. Amiodarone’s high iodine levels can persists for more than 6 months as it is stored in adipose tissues

A

True.

126
Q

What are the effects of amiodarone on thyroid function

A
  1. acute transient suppression of thyroid function, 2. hypothyroidism in patients susceptible to the inhibitory effects of a high iodine load 3. thyrotoxicosis in that can cause either a Jod Basedow effect from the iodine load, in the setting of MNG or incipient Grave’s disease or thyroiditis like condition
127
Q

what is the typical thyroid function test pattern of amiodarone induced thyroid dysfunction

A

increased T4, decrased T3, increased rT3 and transient increased in TSH up to 20 mIU/L

128
Q

Type of Amiodarone induced thyrotoxicosis associated with underlying thyroid abnormality

A

Type I AIT

129
Q

Type of AIT which occurs in individuals with no intrinsic thyroid abnormalities and is the result of drug induced lysosomal activation leadint to destructive thyroiditis with histiocyte accumulation

A

Type II AIT

130
Q

major side effect of perchlorate treatment

A

agranulocytosis

131
Q

what may be given to AIT

A

potassium perchlorate 200 mg every 6 hrs

132
Q

Most sensitive test for hyperthyroidism

A

T4; you cannot distinguish primary thyrotoxicosis without it

133
Q

True or false. Patient with Grave’s disease are at increased risk for thyroid cancer

A

True.

134
Q

how to rule out subacute thryroiditis

A

painful gland and a prior fever

135
Q

True or false. Earliest manifestation of Graves or thyrotoxicosis is elevated T3

A

True.

136
Q

How to rule out destructive thyroiditis,

A

Radioiodine uptake

137
Q

how to rule our secondary hyperhhyroidism due to a TSH secreting pituitary tumor

A

CT scan or MRI

138
Q

True or false. Those who enter remission after treatment develop hypothyroidism

A

True.

139
Q

when ophthalmopathy worsens? Plateau?

A

worsen over the initial 3-6 months; plateau for 1-2 months before resolution

140
Q

True or false. Radioiodine may worsen eye disease esp amokng smokers

A

True.

141
Q

indications of PTU

A

first trimester of pregnancy, treatment of thyroid storm, patient with minor adverse reaction to methimazole

142
Q

True or false. Carbimazole or methimazole also can be given once a day once on euthyroidism

A

True.

143
Q

Baseline liver function tests before starting PTU/methimazole?

A

Yes as it can cause PTU hepatocellular toxicity and cholestasis in methimazole; 5x ULN SGPT to reconsider PTU/methimazole

144
Q

True or false. Block and replace regimen is not well validated way of titrating methimazole

A

True.

145
Q

when is euthyroidism expected

A

6-8 weeks after treatment is initiated

146
Q

when is remission expected

A

achieved y 12-18 months; higher in patients with Trab levels are no longer detected; TRab is sent to Manila and if not detected, treatment may be stopped; anti TPO may be used instead and treatment discontinued if not detected

147
Q

when do you say patient is in remission

A

12 months off antithyroid drugs with no symptoms

148
Q

limit of methimazole to avoid liver problems

A

not more than 40 mg per day to avoid side effects

149
Q

True or false. Baseline CBC is needed; ANC less than 1000; patient should stop methimazole/PTU

A

True.

150
Q

When RAI advocated

A

with co morbidities who cannot undergo surgery, with adverse effects to antithyroid drugs

151
Q

when is antithyroid stopped and resumed before after RAI

A

methimazole stopped 3 days prior to RAI; PTU stopped 7 days prior; antithyroid drugs resumed 7 days after RAI

152
Q

when does radiation thyroiditis occur

A

1-2 weeks after treatment

153
Q

if patient is persistently hyperthyroidism after 2-3 months, when do to repeat RAI

A

Usually 6 months after first dose

154
Q

risk for hypothyroidism after RAI

A

at least 10-20% in the first year

155
Q

True or false. Moderate to severe ophthalmopathy, RAI avoided

A

True.

156
Q

What pre medication of patient with mild ophthalmopathy prior to RAI

A

prednisone

157
Q

True or false. Ophthalmopathy exaggerates if hyperthyroid patient goes into hypothyroidism

A

True.

158
Q

major complications of thyroidectomy

A

bleeding, laryngeal edema, hypoparathyroidism and damage to recurrent laryngeal nerves

159
Q

pre medication prior to thyroidectomy

A

to avoid hungry bone; pre medicate with calcium and vitamin D or calcitriol

160
Q

Can you give SSKI to toxic adenoma or Toxic MNG goiter

A

no; counterproductive

161
Q

for monitoring post treatment in adjusting dose of antithyroid drugs

A

T4

162
Q

True or false. Multiple 1.5 to patient’s result of FT4 and TT4 and still within the range then the rise is related to pregnancy

A

True.

163
Q

True or false. If methimazole 5-10 mg per day or PTU less than 100-200 mg after evaluation, then medication can be discontinued in a newly pregnat women with Grave’s disease

A

True.

164
Q

what beta blocker to be given in pregnant patient with hyperthyroidism

A

propanolol and metoprolol; not atenolol as it is assocaited with restricted fetal growth

165
Q

True or false. Gestation thyrotoxicosis in first 16 weeks of AOG does not need treatment

A

True esp if FT4 is just within high normal

166
Q

specifics in SSKI

A

Give 1 hr after loading dose of PTU in thyroid storm; never before

167
Q

high uptake on RAI. Graves or thyroiditis?

A

Graves’ disease

168
Q

what confers subacute thyroiditis

A

elevated ESR

169
Q

thyroiditis with normal thyroid test all through out

A

subacute thyroiditis

170
Q

postpartum vs subacute v silent thyroiditis

A

Subacute = painful silent= no

171
Q

Medications causing elevated FT4

A

NSAIDs, furosemide, antiepileptics

172
Q

medications that cause low TSH

A

dopamine, steroids, somastostatin, bromocriptine

173
Q

Conditions that increase thyroid hormone by increasing TBG

A

pregnancy, oral contraceptive, hormone therapy, selective estrogen receptor modulators, inflammatory liver disease. Anything that increases estrogen

174
Q

Conditions that decrease total thyroid hormones by decreasing TBG levels

A

androgens, nephrotic syndrome

175
Q

best way to physically examine the thyroid gland

A

palpate each lobe with both lands from behind

176
Q

markers of hashimoto’s thyroiditis

A

positive anti TPO and anti Tg

177
Q

Thyroid scan findings. Enlarged gland with homogenously increased uptake

A

Graves disease

178
Q

Thyroid scan findings. Focal area of increased uptake with suppressed uptake in the remainder of the gland

A

Toxic adenoma

179
Q

Thyroid scan findings. Very low uptake because follicular cell damage and TSH suppression

A

Subacute, viral and postpartum thyroiditis

180
Q

Thyroid scan findings. Low uptake

A

Thyrotoxicosis factitia

181
Q

Dose titration of anit thyroid drugs is based on

A

T4 levels

182
Q

True or false. Beta blockers control adrenergic symptoms after anit thyroid drugs take effect

A

False. Before anti thyroid drugs take effect

183
Q

stopped weeks before radioiodine due to its prolonged radioprotective properties

A

PTU

184
Q

True or false. Graves ophthalmopathy does not parallel with thyroid disease

A

True.

185
Q

How is the critical picture of graves ophthalmopathy

A

worsens in 3-6 months plateaus in the next 12-18 months with spontaneous improvement

186
Q

True or false. RAI can worsen graves ophthalmopathy esp among smokers

A

True.

187
Q

10-10 rule in graves ophthalmopathy

A

ophthalmopathy occurs without hyperthyroidism in 10% and unilateral signs in 10%

188
Q

when is euthyroidism expected once treatment started

A

6-8 weeks

189
Q

when to check FT4 and symptoms of hyperthyroidism

A

4-6 weeks after starting treatment

Endocrine (15 decks)

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