Advanced Thyroid Exam

Question 1

Thyroid anatomy

Answer 1

Question 2

Goiter

Answer 2

Enlargement of the thyroid gland. This can be associated with overproduction, underproduction, or normal production of thyroid hormone. It is associated with several different conditions; therefore, is NOT a diagnosis of the condition, but rather a finding.

Small goiters rarely cause symptoms; however, large ones can lead to symptoms of coughing, hoarseness, difficulty swallowing, or difficulty breathing

Question 3

Graves’ ophthalmopathy

Answer 3

Seen ONLY in Graves’ disease (common cause of hyperthyroidism), this includes exophthalmos (bulging eyes), lid lag, upper eyelid retraction, erythema, and conjunctivitis

Question 4

Thyroid Storm

Answer 4

A rare, life-threatening condition characterized by severe clinical manifestations of thyrotoxicosis. This is an endocrinological emergency.

Question 5

When examining the thyroid, you should always also examine. . .

Answer 5

. . . the adjacent cervical lymph nodes.

Question 6

Questions to investigate during thyroid exam

Answer 6

Question 7

If a lymph node is tender, it is likely __.

Answer 7

If a lymph node is tender, it is likely reactive.

It is the non-painful ones you are worry about - this is far more likely to be cancerous.

Question 8

Pemberton’s sign

Answer 8

The sign is positive when bilateral arm elevation causes facial plethora. It has been attributed to a “cork effect” resulting from the thyroid obstructing the thoracic inlet, thereby increasing pressure on the venous system. Effectively, you are reproducing SVC syndrome.

Used to evaluate venous obstruction in patients with goiters. Often present along with dysphagia from goiter.

Question 9

Auscultating the thyroid

Answer 9

In a patient with Grave’s disease, you may hear a continuous bruit within the thyroid gland if you put your stethoscope up to the goiter.

Question 10

Myxedema Coma

Answer 10

Coma that may be induced by severe hypothyroidism.

Patients will present as below, often with very prominent facial edema.

This is a medical emergency with high mortality.

Question 11

Pretibial Myxedema

Answer 11

Sign of unreated Grave’s disease specifically

Localized lesions of the skin resulting from the deposition of hyaluronic acid.

Question 12

Eye pathology in myxedema vs in Grave’s

Answer 12

In myxedema from hypothyroidism, there will be edema surrounding the eyes

In Grave’s, there is increased eyelid muscle tone and edema behind the eyes

Question 13

Schzatke’s Ring

Answer 13

A Schatzki ring is a circular band of mucosal tissue that can form at the end of the esophagus.

Question 14

Pork thyroid weight loss supplement

Answer 14

Can legitimately cause pathologic symptoms, contains residual T3/T4 that may induce transient hyperthyroidism or thyrotoxicosis.

Question 15

Rare side effect of methimazole

Answer 15

Agranulocytosis (neutropenia)

Question 16

In transient thyroiditis resulting in release of pre-formed thyroid hormone, the predominant isoform will be ___.

Answer 16

In transient thyroiditis resulting in release of pre-formed thyroid hormone, the predominant isoform will be T4.

That is because most of the thyroid hormone is stored as T4 in the medulla of the thyroid

Question 17

Checkpoint inhibitor-induced thyroiditis

Answer 17

Name explains it, but know that it is a thing. Basically just Hashimoto’s.

Question 18

Severe hyperthyroidism vs thyrotoxicosis

Answer 18

Hyperthyroidism is a laboratory finding

Thyrotoxicosis is the clinical syndrome of excessive thyroid hormone activity

Question 19

Thyroid bruit is seen in. . .

Answer 19

. . . Grave’s disease only

Question 20

Lid lag

Answer 20

Due to inflammation of the lid and delayed action of the muscle, when eyes are moved up to follow a rising object, the lids will lag behind slightly.

Question 21

Features specific to Grave’s

Answer 21

Pretibial myxedema

Proptosis

Thyroid bruit

Question 22

What is a situation in which you should use PTU over methimazole for treating hyperthyroidism?

Answer 22

If the patient is pregnant!

Methimazole is teratogenic, especially in the first trimester.

Question 23

___ should always be on the differential for hypothyroidism with psychiatric involvement.

Answer 23

Depression should always be on the differential for hypothyroidism with psychiatric involvement.

Question 24

Specific reflex findings in hypothyroidism

Answer 24

Relaxation takes much longer, even though the reflex itself is prompt

Especially well seen on the ankle-jerk reflex

Not always present, usually there in severe hypothyroidism.

Question 25

If you get hypothyroid results that are abnormal, but not that abnormal, you should. . .

Answer 25

. . . have the patient come back in a few weeks and repeat, to ensure that this is true hypothyroidism.

Question 26

Tips for taking levothyroxine properly

Answer 26

Question 27

How long will it take for levothyroxine to alleviate the effects of hypothyroidism

Answer 27

Weeks to months.

This is not an instantaneous fix.

Question 28

When a hypothyroid patient on levothyroxine becomes pregnant, they should. . .

Answer 28

. . . increase their dosage! Usually this is done in the short-term by telling them to take the same dosage daily, but just take two pills on Fridays.

But! Additionally! These patients should be checked for Grave’s. Remember that fetal Grave’s is a thing. And refer them to an endocrinologist too.