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Year 2 - Endocrinology (DP) > Clinical (Week 3 - Thyroid and Adrenal) > Flashcards

Clinical (Week 3 - Thyroid and Adrenal) Flashcards

1
Q

What is the most common kind of thyroid cancer?

A

Papillary

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2
Q

What type of thyroid cancer has the worst prognosis?

A

Anaplastic

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3
Q

What does differentiated mean in terms of cancer?

A

Difficult to tell between normal thyroid cells and the cancer cells

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4
Q

What do most thyroid cancers take up and secrete?

A

Thyroglobulin

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5
Q

What drives differentiation thyroid cancers?

A

TSH

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6
Q

What populations have a decreased risk of differentiated thyroid cancer?

A

Afro-Americans

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7
Q

What is differentiated thyroid cancer strongly associated with?

A

Lymphoma treatment

Nuclear incidents

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8
Q

What is differentiated thyroid cancer weakly associated with?

A

Thyroid adenomata
Chronically increased TSH
Increased parity

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9
Q

What do most differentiated thyroid cancers present with?

A

Palpable nodules

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10
Q

How does papillary thyroid cancer spread and where to?

A

Lymphatic:

 - Lungs
 - Bone
 - Liver
 - Brain
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11
Q

What is papillary thyroid cancer associated with?

A

Hashimoto’s thyroiditis

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12
Q

In what areas is the incidence of follicular carcinoma increased?

A

Regions of relative iodine deficiency

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13
Q

How does follicular carcinoma spread?

A

Haematogenously

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14
Q

What is the gold-standard investigation for a suspected thyroid cancer?

A

USS-guided FNA

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15
Q

Which of the following is not a negative clinical predictor of malignancy:

  • New nodule age 50
  • Male
  • Nodule increasing in size
  • Lesion >4cm
  • Heavy smoker
  • Head/Neck irradiation
  • Vocal cord palsy
A

Heavy smoker

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16
Q

What is the first line management for thyroid cancer?

A

Surgery:

 - Thyroid lobectomy with isthmusectomy
 - Subtotal thyroidectomy
 - Total thyroidectomy
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17
Q

How can we calculate the post-operative risk in thyroid cancer?

A

A - Age
M - Metastases
E - Extend of primary tumour
S - Size of primary tumour

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18
Q

Which of the following is not a feature of an AMES high risk individual:
- Age 5cm

A

Age

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19
Q

When is a thyroid lobectomy with isthmusectomy used?

A

Papillary microadenoma (

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20
Q

What is the gold-standard operative management for thyroid cancer?

A

Sub-total thyroidectomy

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21
Q

What is important in the post-operative care in thyroid cancer?

A

Check calcium within 24 hours:
- All parathyroid glands may be removed
Replace calcium is corrected calcium

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22
Q

What must post-operative patients be discharged with following a sub-total thyroidectomy?

A

T4 (or T3)

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23
Q

When is whole body iodine scanning used and what must be done beforehand?

A

Patients who had a sub-total/total thyroidectomy:
- 3-6 months post-op
T4 stopped 4 weeks prior; T3 stopped 2 weeks prior

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24
Q

What level of TSH would give the best results for a whole body iodine scan?

A

> 20

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25
Q

What is the procedure for whole body iodine scanning?

A

2-4mCi (75-150MBq) I-131 capsule on the Tuesday

Imaging on Friday

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26
Q

What happens if the uptake on whole body iodine scanning is >0.1% of ingested activity?

A

Thyroid Remnant Ablation (the following Tuesday)

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27
Q

What is the process of thyroid remnant ablation?

A

Admitted to a lead-lined rooms with mains sewage

2 or 3 GBq capsule of I-131 administered

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28
Q

What are some side effects of thyroid remnant ablation?

A

Sialadenitis (Salivary gland inflammation)

Sore throat

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29
Q

What precautions must be taken during thyroid remnant ablation?

A

Disposable cutlery and sheets
Store patients clothing
Little/no nurse or visitor contact

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30
Q

When is a patient discharged after thyroid remnant ablation?

A

When count rate

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31
Q

What are the aims of thyroid remnant ablation?

A

Suppress TSH

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32
Q

What is thyroglobulin used as a marker for?

A

Remaining tumour

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33
Q

What should also be measured alongside thyroglobulin? Apart from after ablation when should it be measured?

A

Anti-thyroglobulin antibodies
Pre-op:
- Not all patient tumours secrete Tg

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34
Q

What are some long-term complications of thyroid remnant ablation?

A

Small increase in risk of acute myeloid leukaemia

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35
Q

What bounds the anterior neck triangle?

A

Mandible superiorly
Midline medially
Anterior border of SCM laterally

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36
Q

What bounds the posterior neck triangle?

A

Posterior border of SCM anteriorly
Anterior border of trapezius laterally
Clavicle inferiorly

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37
Q

What are some causes of a superficial neck swelling?

A

Sebaceous cysts
Lipomas
Neurofibromas

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38
Q

What position should a patient be in for examining their neck?

A

Seated in good light

Neck partly extended

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39
Q

What can cause cervical lymphadenopathy?

A

Infection
Malignancy
Leukaemia/Lymphoma

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40
Q

What systemic symptoms can be present and what might these indicate in regard to cervical lymphadenopathy?

A 
Fever
Weight loss
Sweats
Might indicate:
     - Hodgkin's Lymphoma
     - TB
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41
Q

If examining a thyroid swelling, what term is used to describe the following findings:

  • One lump
  • More than one lump
A
  • Solitary

- Multinodular goitre

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42
Q

What causes of midline swellings move on swallowing?

A

Thyroid

Thyroglossal cyst

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43
Q

What causes of midline swellings move on sticking out the tongue?

A

Thyroglossal cyst

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44
Q

Why might a thyroglossal cyst become infected?

A

It contains lymphatics

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45
Q

What age group do thyroglossal cysts present in?

A

Teen years

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46
Q

A 16 year old boy present with a soft, non-fluctuant midline neck swelling. On examination it doesn’t move with swallowing or on sticking out the tongue.

A

Dermoid cyst

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47
Q

In what region of the neck does a branchial cyst present?

A

Upper anterior triangle

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48
Q

What is a branchial cyst?

A

Persisting second branchial arch

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49
Q

How could a branchial cyst be described?

A

Half-filled hot water bottle

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50
Q

On FNA, what would be seen in a branchial cyst?

A

Cholesterol crystals

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51
Q

What happens if a branchial cyst fistulates?

A

Saliva leaks out anterior to SCM

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52
Q

What are other causes of anterior neck swellings?

A

Lymph nodes
Salivary glands
Carotid body tumour

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53
Q

A 9 month old child presents with a large neck swelling in their posterior neck triangle. On examination it transilluminates.

A

Cystic hygroma

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54
Q

What is a cystic hygroma filled with?

A

Lymph

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55
Q

Why are stones more common in the submandibular glands?

A

Saliva is more mucous-y

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56
Q

What is the most common pathology affected the parotid gland?

A

Infection

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57
Q

Why are stones less common in the parotid gland?

A

Saliva is more serous

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58
Q

On FNA what do the following mean and what should be done after:

  • Thy 1
  • Thy 2
  • Thy 3
  • Thy 4/5
A 
Thy 1:
     - Inadequate
     - Repeat FNA
Thy 2:
     - Benign
     - Repeat FNA in 6 months
Thy 3:
     - Suspicious
     - Thyroid lobectomy
Thy 4/5:
     - Malignant
     - Total thyroidectomy
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59
Q

What T4/T3 + TSH levels would be expected in each of the following:

  • Hyperthyroidism
  • Hypothyroidism
  • TSHoma
  • Pituitary gland failure
A 
Hyperthyroidism:
     - T4/T3 high
     - TSH low
Hypothyroidism:
     - T4/T3 low
     - TSH high
TSHoma:
     - TSH high
     - T4/T3 high
Pituitary gland failure:
     - TSH low
     - T4/T3 low
60
Q

What does myxoedema mean in terms of hypothyroidism?

A

Severe hypothyroidism can cause a myxoedema coma

61
Q

What cause of hypothyroidism present with a goitre?

A 
Hashimoto's Thyroiditis
Hereditary defects
Maternally transmitted
Iodine deficiency
Drug induced
62
Q

What drugs can induce hypothyroidism?

A

Amiodarone
Lithium
IFN-α

63
Q

What can cause a self-limiting hypothyroidism?

A

After withdrawal of suppressive therapy
Thyroiditis with transiet hypothyroidism
Postpartum thyroiditis

64
Q

What are some hypothalamic causes of secondary hypothyroidism?

A

Congenital
Infection (Encephalitis)
Infiltration (Sarcoidosis)
Malignancy (Craniopharyngioma)

65
Q

What are some pituitary causes of secondary hypothyroidism?

A 
Panhypopituitarism:
     - Trauma
     - Infection
     - Infiltration
     - Neoplasm
Isolated TSH deficiency
66
Q

What are some risk factors for autoimmune thyroiditis?

A

FHx of thyroid/autoimmune disease

Female

67
Q

What is autoimmune hypothyroidism characterised by?

A

Thyroid Peroxidase Antibodies (in blood)
Microscopy:
- T cell infiltrate
- Inflammation

68
Q

Which of the following is not a hair and cutaneous sign of hypothyroidism:

  • Dull face
  • Periorbital puffiness
  • Vitiligo
  • Thickened hair
A

Thickened hair (It is actually coarse and sparse)

69
Q

In hypothyroidism, are patient’s intolerant to the cold or the heat?

A

Cold

70
Q

What are some cardiac features of hypothyroidism?

A

Reduced heart rate
Cardiac dilation
Pericardial effusion
Worsening of CHF

71
Q

What other biochemical results might be seen in hypothyroidism?

A 
Macrocytosis (Increased MVC >100 fL):
     - Rule out Vit. B12 deficiency
Increased levels of:
     - Cretinine kinase
     - LDL
Hyponatraemia
Hyperprolactinaemia
72
Q

What TSH receptor antibodies are seen in:

  • Grave’s Disease
  • Autoimmune hypothyroidism
A

Grave’s:
- Stimulating
Autoimmune hypothyroidism:
- Blocking

73
Q

What might happen if hypothyroidism is corrected too rapidly?

A

Cardiac arryhthmias

74
Q

How is hypothyroidism treated?

A

Start thyroxine:

 - Young patients -> 50-100μg daily
 - Elderly with IDH -> 25-50μg daily (Adjusted monthly(
75
Q

When is TSH checked during hypothyroidism treatment?

A

2 months after a dose change
One stabile:
- Every 12-18 months

76
Q

When is thyroxine taken?

A

Before breakfast

77
Q

When is T3 used?

A

If T4 not tolerated

78
Q

What do you do to a patient’s T4 dose if they are pregnant?

A

Increase it by 25-50%

79
Q

How do you monitor the success of treatment in:

  • Primary hypothyroidism
  • Secondary hypothyroidism
A

Primary:
- TSH
Secondary:
- T4

80
Q

An elderly woman presents to A&E with reduced consciousness. She has long-standing hypothyroidism that is poorly managed. On ECG there is bradycardia, evidence of heart block and some QT-prolongation. An ABG is taken, her PaO2 is 7.2kPa, her PaCO2 is 11.5kPa and her pH is 7.29.

A

Myxoedema coma

81
Q

How is a myxoedema coma treated?

A

ICU:

 - Slowly increase body temperature
 - Monitor ECG
 - FLuids
 - Broad spectrum antibiotics
 - Thyroxine cautions (hydrocortisone)
82
Q

What are some common causes of hyperthyroidism?

A 
Autoimmune (Grave's Disease)
Nodular thyroid:
     - MNG
     - Toxic nodule -> Adenoma
Thyroiditis:
     - Subactue
     - Postpartum
83
Q

What is seen on scintigraphy if the patient has Grave’s disease?

A

Smooth symmetrical goitre:

- High uptake

84
Q

What are ophthalmology features of Grave’s disease?

A 
Lid retraction
Chemosis (Swollen conjunctiva)
Proptosis
Visual loss
Diplopia
85
Q

What causes the ophthalmology features in Grave’s disease?

A

Antibodies

86
Q

How can ophthalmology features be treated?

A 
Lubricants
Decompression
Radiotherapy
Surgery
Smoking cessation
87
Q

What patient’s tend to suffer from nodular thyroid disease?

A

Older people

88
Q

How does a nodular thyroid appear on scintigraphy?

A

Assymetrical (High uptake)

89
Q

How does a thyroid storm present?

A

Respiratory and cardiac collapse
Hyperthermia
Exaggerated reflexes

90
Q

How do you treat a thyroid storm?

A 
Lugols idoine
Glucocorticoids
Propylthiouracil
β-blockers
Fluids
91
Q

How is hyperthyroidism treated?

A

Oral medication:

 - Carbimazole
 - Propylthiouracil
92
Q

How are oral medications used in Grave’s?

A

Started at high dose:

 - Decrease over 12-18 months
 - Then stop
93
Q

What can hyperthyroidism treatment cause?

A

Agranulocytosis

94
Q

What hyperthyroidism treatment is preferred in pregnancy?

A

Propylthiouracil

95
Q

Which of the following is not a precaution in the use of radio-iodine for the treatment of hyperthyroidism:

  • Avoid contact with kids and pregnant women
  • No bed-sharing
  • Avoid pregnancy for a month
  • High risk of hypothyroidism
A

Avoid pregnancy for a month:

- Should be avoided for 6 months

96
Q

A 31 year old woman present with a sore swelling in her neck and a fever. She says she had the flu a couple of weeks ago. Her TSH is high and T4 is low. There is low uptake on Scintigraphy.

A

De Quervain’s/Subacute Thyroiditis

97
Q

What hormone does the ovum produce?

A

Oestradiol

98
Q

What hormone does the corpus luteum produce?

A

Progesterone

99
Q

What hormone is tested for by a pregnancy test?

A

Human Chorionic Gonadotropin

100
Q

What hormones does the placenta produce?

A

Human Placental Lactogen (hPL)
Placental progesterone
Placental Oestrogens

101
Q

What is the pathogenesis behind gestational diabetes?

A
  1. Increased levels of progesterone + hPL
  2. Insulin resistance in mum
  3. Increased blood glucose
  4. Gestational DM (Late 2nd -> 3rd trimester)
102
Q

What neonatal complications are at a higher incidence in diabetes?

A 
CNS defects (5x):
     - Anencephaly
     - Spina Bifida
Caudal regression syndrome (200x)
Ureteric duplication (20x)
103
Q

What does maternal hyperglycaemia result in?

A

Foetal hyperglycaemia:
> Foetal hyperinsulinaemia
> Macrosomia (birth weight > 4kg)
> Neonatal hypoglycaemia

104
Q

What does insulin act as in the 3rd trimester?

A

A major growth factor

105
Q

What drugs should be avoided in diabetes during pregnancy?

A

ACE inhibitors:
- Use labetalol, Nifedipine or Methyl dopa instead
Statins

106
Q

What should blood glucose be during pregnancy?

A

Pre-meal -

107
Q

How can good blood glucose be maintained during pregnancy?

A

IV insulin

IV dextrose

108
Q

How is MODY managed?

A

Glibenclamide

109
Q

How is gestational diabetes managed?

A

Lifestyle
Metformin -> May need insulin
6 week post-natal GTT to ensure resolution

110
Q

What hormone is very important for foetal development?

A

Thyroxine

111
Q

What happens to thyroid demand and plasma protein binding during pregnancy?

A

Both increase

112
Q

What hormones are often high in hyperemesis gravidarum?

A

hCG

TSH/fT4

113
Q

How does the thyroid meet the increased demand during pregnancy?

A

Increases in size

Increases fT4 production

114
Q

As soon as pregnancy is expected, what must be done to the thyroxine dose for patients suffering from hypothyroidism?

A

Increase the dose by 25μg

115
Q

How often are TFTs checked during pregnancy?

A

Monthly for 1st 20 weeks

Every 2 months until term

116
Q

What should the TSH aims be during pregnancy?

A
117
Q

Untreated hypothyroidism increases the incidence of what complications during pregnancy?

A 
Abortion
Pre-eclampsia
Abruption
Postpartum haemorrhage
Preterm labour
118
Q

What are some features of gestational hCG-associated thyrotoxicosis?

A

Hyperemesis gravidarum:
- Increased hCG -> Decreased TSH
Resolves by 20 weeks gestation
Only treat is persisting longer than 20 weeks

119
Q

How does hCG cause an increased release of T4?

A

Very similar structure to TSH:
- Both two chain peptides
> α-chains identical
> β-chains different

120
Q

How can we treat hyperthyroidism during pregnancy?

A

β-blockers if needed
LOW DOSE anti-thyroid drugs:
- Propylthiouracil during 1st trimester
- Carbimazole during 2nd + 3rd trimester

121
Q

What can carbimazole cause during pregnancy?

A

Embryopathy
Scalp/GI abnormalities
Choanal and oesophageal atresia

122
Q

A woman presents do the GP with a small swelling in her neck. You find out she gave birth 3 months ago. On examination of the neck, the thyroid is slightly swollen and isn’t tender. TFTs show a reduced T4 and slightly raised TSH.

A

Post-Partum Thyroiditis

123
Q

What does CRH stimulate?

A

Release of ACTH from anterior pituitary

124
Q

What does TRH stimulate?

A

TSH release from anterior pituitary

125
Q

What does GnRH stimulate?

A

LH/FSH release from anterior pituitary

126
Q

What does GHRH stimulate?

A

Release of GH from anterior pituitary

127
Q

What effect does dopamine have?

A

Inhibits prolactin release

128
Q

What is Cushing’s Syndrome?

A

Excess cortisol

129
Q

What effect does Cushing’s syndrome have on protein and how does this manifest?

A 
Protein is lost:
     - Myopathy -> Wasting
     - Osteoporosis -> Fractures
     - Thin skin
               > Striae
               > Bruising
130
Q

What does the excess mineralocorticoid cause in Cushing’s?

A

Hypertension

Oedema

131
Q

What does the excess androgen cause in Cushing’s?

A

Virilism
Hirsutism
Acne
Oligo/Amenorrhoea

132
Q

What distinguishes Cushing’s from obesity?

A 
Thin skin
Proximal myopathy
Frontal balding in women
Chemosis
Osteoporosis
133
Q

What are some screening tests for Cushing’s?

A 
Overnight 1mg PO dexamethasone suppression:
     - Cortisol  Normal
     - Cortisol >100nmol/L -> Abnormal
Urine free cortisol (24hr):
     - Total
134
Q

What is the definitive test for diagnosing Cushing’s?

A

Two day 2mg/day low dose DST:

- Cortisol No Cushing’s

135
Q

What can cause an ectopic production of ACTH?

A

Thymus
Small-cell lung cancer
Pancreas

136
Q

How is pituitary Cushing’s (Cushing’s disease) treated?

A

Hypophysectomy + External radiotherapy if it recurs

137
Q

How is adrenal Cushing’s treated?

A

Adrenalectomy

138
Q

How is ectopic Cushing’s treated?

A

Remove source
OR
Bilateral adrenalectomy

139
Q

What is the drug treatment for Cushing’s and when is it used?

A

Metyrapone:

 - If other treatments fail
 - While waiting for radiotherapy to work
140
Q

How does pan-hypopituitarism present?

A 
Growth failure
Hypothyroidism
Hypogonadism
Hypoadrenal
Diabetes Insipidus
141
Q

What local brain tumours can cause hypopituitarism?

A

Astrocytoma
Meningioma
Glioma

142
Q

What granulomatous disease can cause hypopituitarism?

A

TB
Histiocytosis X
Sarcoidosis

143
Q

What effects does growth hormone have in adults?

A 
Reduces abdominal fat
Increases:
     - Muscle mass
     - Strength
     - Stamina
Improves cardiac function
Reduces cholesterol and LDL
Increases bone density
144
Q

What are some risks of testosterone replacement?

A

Prostate enlargement
Polycythaemia
Hepatitis

145
Q

What dose the following stand for in terms of a familial presentation of cranial diabetes insipidus DIDMOAD?

A

DI
DM
Optic Atrophy
Deaf

146
Q

How is diabetes insipidus diagnosed?

A

Water deprivation test:
- Urine osmolarity will fall to less than 300mOsm/kg

Give desmopressin:

  • Cranial DI (Urine osmolarity rises by over 50%)
  • Nephrogenic DI (Less than 50% rise)
147
Q

How can DI be treated?

A 
Desmospray:
     - Nasally -> 10-60micrograms daily
Oral desmopressin:
     - 100-1000micrograms daily
Sublingual desmopressin:
     - 60-360micrograms daily
Desmopressin injection:
     - IM -> 1-2micrograms daily

Year 2 - Endocrinology (DP) (15 decks)

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