Clinical (Week 3 - Thyroid and Adrenal) Flashcards
1
Q
What is the most common kind of thyroid cancer?
A
Papillary
2
Q
What type of thyroid cancer has the worst prognosis?
A
Anaplastic
3
Q
What does differentiated mean in terms of cancer?
A
Difficult to tell between normal thyroid cells and the cancer cells
4
Q
What do most thyroid cancers take up and secrete?
A
Thyroglobulin
5
Q
What drives differentiation thyroid cancers?
A
TSH
6
Q
What populations have a decreased risk of differentiated thyroid cancer?
A
Afro-Americans
7
Q
What is differentiated thyroid cancer strongly associated with?
A
Lymphoma treatment
Nuclear incidents
8
Q
What is differentiated thyroid cancer weakly associated with?
A
Thyroid adenomata
Chronically increased TSH
Increased parity
9
Q
What do most differentiated thyroid cancers present with?
A
Palpable nodules
10
Q
How does papillary thyroid cancer spread and where to?
A
Lymphatic:
- Lungs - Bone - Liver - Brain
11
Q
What is papillary thyroid cancer associated with?
A
Hashimoto’s thyroiditis
12
Q
In what areas is the incidence of follicular carcinoma increased?
A
Regions of relative iodine deficiency
13
Q
How does follicular carcinoma spread?
A
Haematogenously
14
Q
What is the gold-standard investigation for a suspected thyroid cancer?
A
USS-guided FNA
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
16
Q
What is the first line management for thyroid cancer?
A
Surgery:
- Thyroid lobectomy with isthmusectomy - Subtotal thyroidectomy - Total thyroidectomy
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
18
Q
Which of the following is not a feature of an AMES high risk individual:
- Age 5cm
A
Age
19
Q
When is a thyroid lobectomy with isthmusectomy used?
A
Papillary microadenoma (
20
Q
What is the gold-standard operative management for thyroid cancer?
A
Sub-total thyroidectomy
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
22
Q
What must post-operative patients be discharged with following a sub-total thyroidectomy?
A
T4 (or T3)
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
24
Q
What level of TSH would give the best results for a whole body iodine scan?
A
> 20
25
What is the procedure for whole body iodine scanning?
2-4mCi (75-150MBq) I-131 capsule on the Tuesday
| Imaging on Friday
26
What happens if the uptake on whole body iodine scanning is >0.1% of ingested activity?
Thyroid Remnant Ablation (the following Tuesday)
27
What is the process of thyroid remnant ablation?
Admitted to a lead-lined rooms with mains sewage
| 2 or 3 GBq capsule of I-131 administered
28
What are some side effects of thyroid remnant ablation?
Sialadenitis (Salivary gland inflammation)
| Sore throat
29
What precautions must be taken during thyroid remnant ablation?
Disposable cutlery and sheets
Store patients clothing
Little/no nurse or visitor contact
30
When is a patient discharged after thyroid remnant ablation?
When count rate
31
What are the aims of thyroid remnant ablation?
Suppress TSH
32
What is thyroglobulin used as a marker for?
Remaining tumour
33
What should also be measured alongside thyroglobulin? Apart from after ablation when should it be measured?
Anti-thyroglobulin antibodies
Pre-op:
- Not all patient tumours secrete Tg
34
What are some long-term complications of thyroid remnant ablation?
Small increase in risk of acute myeloid leukaemia
35
What bounds the anterior neck triangle?
Mandible superiorly
Midline medially
Anterior border of SCM laterally
36
What bounds the posterior neck triangle?
Posterior border of SCM anteriorly
Anterior border of trapezius laterally
Clavicle inferiorly
37
What are some causes of a superficial neck swelling?
Sebaceous cysts
Lipomas
Neurofibromas
38
What position should a patient be in for examining their neck?
Seated in good light
| Neck partly extended
39
What can cause cervical lymphadenopathy?
Infection
Malignancy
Leukaemia/Lymphoma
40
What systemic symptoms can be present and what might these indicate in regard to cervical lymphadenopathy?
```
Fever
Weight loss
Sweats
Might indicate:
- Hodgkin's Lymphoma
- TB
```
41
If examining a thyroid swelling, what term is used to describe the following findings:
- One lump
- More than one lump
- Solitary
| - Multinodular goitre
42
What causes of midline swellings move on swallowing?
Thyroid
| Thyroglossal cyst
43
What causes of midline swellings move on sticking out the tongue?
Thyroglossal cyst
44
Why might a thyroglossal cyst become infected?
It contains lymphatics
45
What age group do thyroglossal cysts present in?
Teen years
46
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.
Dermoid cyst
47
In what region of the neck does a branchial cyst present?
Upper anterior triangle
48
What is a branchial cyst?
Persisting second branchial arch
49
How could a branchial cyst be described?
Half-filled hot water bottle
50
On FNA, what would be seen in a branchial cyst?
Cholesterol crystals
51
What happens if a branchial cyst fistulates?
Saliva leaks out anterior to SCM
52
What are other causes of anterior neck swellings?
Lymph nodes
Salivary glands
Carotid body tumour
53
A 9 month old child presents with a large neck swelling in their posterior neck triangle. On examination it transilluminates.
Cystic hygroma
54
What is a cystic hygroma filled with?
Lymph
55
Why are stones more common in the submandibular glands?
Saliva is more mucous-y
56
What is the most common pathology affected the parotid gland?
Infection
57
Why are stones less common in the parotid gland?
Saliva is more serous
58
On FNA what do the following mean and what should be done after:
- Thy 1
- Thy 2
- Thy 3
- Thy 4/5
```
Thy 1:
- Inadequate
- Repeat FNA
Thy 2:
- Benign
- Repeat FNA in 6 months
Thy 3:
- Suspicious
- Thyroid lobectomy
Thy 4/5:
- Malignant
- Total thyroidectomy
```
59
What T4/T3 + TSH levels would be expected in each of the following:
- Hyperthyroidism
- Hypothyroidism
- TSHoma
- Pituitary gland failure
```
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
What does myxoedema mean in terms of hypothyroidism?
Severe hypothyroidism can cause a myxoedema coma
61
What cause of hypothyroidism present with a goitre?
```
Hashimoto's Thyroiditis
Hereditary defects
Maternally transmitted
Iodine deficiency
Drug induced
```
62
What drugs can induce hypothyroidism?
Amiodarone
Lithium
IFN-α
63
What can cause a self-limiting hypothyroidism?
After withdrawal of suppressive therapy
Thyroiditis with transiet hypothyroidism
Postpartum thyroiditis
64
What are some hypothalamic causes of secondary hypothyroidism?
Congenital
Infection (Encephalitis)
Infiltration (Sarcoidosis)
Malignancy (Craniopharyngioma)
65
What are some pituitary causes of secondary hypothyroidism?
```
Panhypopituitarism:
- Trauma
- Infection
- Infiltration
- Neoplasm
Isolated TSH deficiency
```
66
What are some risk factors for autoimmune thyroiditis?
FHx of thyroid/autoimmune disease
| Female
67
What is autoimmune hypothyroidism characterised by?
Thyroid Peroxidase Antibodies (in blood)
Microscopy:
- T cell infiltrate
- Inflammation
68
Which of the following is not a hair and cutaneous sign of hypothyroidism:
- Dull face
- Periorbital puffiness
- Vitiligo
- Thickened hair
Thickened hair (It is actually coarse and sparse)
69
In hypothyroidism, are patient's intolerant to the cold or the heat?
Cold
70
What are some cardiac features of hypothyroidism?
Reduced heart rate
Cardiac dilation
Pericardial effusion
Worsening of CHF
71
What other biochemical results might be seen in hypothyroidism?
```
Macrocytosis (Increased MVC >100 fL):
- Rule out Vit. B12 deficiency
Increased levels of:
- Cretinine kinase
- LDL
Hyponatraemia
Hyperprolactinaemia
```
72
What TSH receptor antibodies are seen in:
- Grave's Disease
- Autoimmune hypothyroidism
Grave's:
- Stimulating
Autoimmune hypothyroidism:
- Blocking
73
What might happen if hypothyroidism is corrected too rapidly?
Cardiac arryhthmias
74
How is hypothyroidism treated?
Start thyroxine:
- Young patients -> 50-100μg daily
- Elderly with IDH -> 25-50μg daily (Adjusted monthly(
75
When is TSH checked during hypothyroidism treatment?
2 months after a dose change
One stabile:
- Every 12-18 months
76
When is thyroxine taken?
Before breakfast
77
When is T3 used?
If T4 not tolerated
78
What do you do to a patient's T4 dose if they are pregnant?
Increase it by 25-50%
79
How do you monitor the success of treatment in:
- Primary hypothyroidism
- Secondary hypothyroidism
Primary:
- TSH
Secondary:
- T4
80
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.
Myxoedema coma
81
How is a myxoedema coma treated?
ICU:
- Slowly increase body temperature
- Monitor ECG
- FLuids
- Broad spectrum antibiotics
- Thyroxine cautions (hydrocortisone)
82
What are some common causes of hyperthyroidism?
```
Autoimmune (Grave's Disease)
Nodular thyroid:
- MNG
- Toxic nodule -> Adenoma
Thyroiditis:
- Subactue
- Postpartum
```
83
What is seen on scintigraphy if the patient has Grave's disease?
Smooth symmetrical goitre:
| - High uptake
84
What are ophthalmology features of Grave's disease?
```
Lid retraction
Chemosis (Swollen conjunctiva)
Proptosis
Visual loss
Diplopia
```
85
What causes the ophthalmology features in Grave's disease?
Antibodies
86
How can ophthalmology features be treated?
```
Lubricants
Decompression
Radiotherapy
Surgery
Smoking cessation
```
87
What patient's tend to suffer from nodular thyroid disease?
Older people
88
How does a nodular thyroid appear on scintigraphy?
Assymetrical (High uptake)
89
How does a thyroid storm present?
Respiratory and cardiac collapse
Hyperthermia
Exaggerated reflexes
90
How do you treat a thyroid storm?
```
Lugols idoine
Glucocorticoids
Propylthiouracil
β-blockers
Fluids
```
91
How is hyperthyroidism treated?
Oral medication:
- Carbimazole
- Propylthiouracil
92
How are oral medications used in Grave's?
Started at high dose:
- Decrease over 12-18 months
- Then stop
93
What can hyperthyroidism treatment cause?
Agranulocytosis
94
What hyperthyroidism treatment is preferred in pregnancy?
Propylthiouracil
95
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
Avoid pregnancy for a month:
| - Should be avoided for 6 months
96
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.
De Quervain's/Subacute Thyroiditis
97
What hormone does the ovum produce?
Oestradiol
98
What hormone does the corpus luteum produce?
Progesterone
99
What hormone is tested for by a pregnancy test?
Human Chorionic Gonadotropin
100
What hormones does the placenta produce?
Human Placental Lactogen (hPL)
Placental progesterone
Placental Oestrogens
101
What is the pathogenesis behind gestational diabetes?
1. Increased levels of progesterone + hPL
2. Insulin resistance in mum
3. Increased blood glucose
4. Gestational DM (Late 2nd -> 3rd trimester)
102
What neonatal complications are at a higher incidence in diabetes?
```
CNS defects (5x):
- Anencephaly
- Spina Bifida
Caudal regression syndrome (200x)
Ureteric duplication (20x)
```
103
What does maternal hyperglycaemia result in?
Foetal hyperglycaemia:
> Foetal hyperinsulinaemia
> Macrosomia (birth weight > 4kg)
> Neonatal hypoglycaemia
104
What does insulin act as in the 3rd trimester?
A major growth factor
105
What drugs should be avoided in diabetes during pregnancy?
ACE inhibitors:
- Use labetalol, Nifedipine or Methyl dopa instead
Statins
106
What should blood glucose be during pregnancy?
Pre-meal -
107
How can good blood glucose be maintained during pregnancy?
IV insulin
| IV dextrose
108
How is MODY managed?
Glibenclamide
109
How is gestational diabetes managed?
Lifestyle
Metformin -> May need insulin
6 week post-natal GTT to ensure resolution
110
What hormone is very important for foetal development?
Thyroxine
111
What happens to thyroid demand and plasma protein binding during pregnancy?
Both increase
112
What hormones are often high in hyperemesis gravidarum?
hCG
| TSH/fT4
113
How does the thyroid meet the increased demand during pregnancy?
Increases in size
| Increases fT4 production
114
As soon as pregnancy is expected, what must be done to the thyroxine dose for patients suffering from hypothyroidism?
Increase the dose by 25μg
115
How often are TFTs checked during pregnancy?
Monthly for 1st 20 weeks
| Every 2 months until term
116
What should the TSH aims be during pregnancy?
117
Untreated hypothyroidism increases the incidence of what complications during pregnancy?
```
Abortion
Pre-eclampsia
Abruption
Postpartum haemorrhage
Preterm labour
```
118
What are some features of gestational hCG-associated thyrotoxicosis?
Hyperemesis gravidarum:
- Increased hCG -> Decreased TSH
Resolves by 20 weeks gestation
Only treat is persisting longer than 20 weeks
119
How does hCG cause an increased release of T4?
Very similar structure to TSH:
- Both two chain peptides
> α-chains identical
> β-chains different
120
How can we treat hyperthyroidism during pregnancy?
β-blockers if needed
LOW DOSE anti-thyroid drugs:
- Propylthiouracil during 1st trimester
- Carbimazole during 2nd + 3rd trimester
121
What can carbimazole cause during pregnancy?
Embryopathy
Scalp/GI abnormalities
Choanal and oesophageal atresia
122
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.
Post-Partum Thyroiditis
123
What does CRH stimulate?
Release of ACTH from anterior pituitary
124
What does TRH stimulate?
TSH release from anterior pituitary
125
What does GnRH stimulate?
LH/FSH release from anterior pituitary
126
What does GHRH stimulate?
Release of GH from anterior pituitary
127
What effect does dopamine have?
Inhibits prolactin release
128
What is Cushing's Syndrome?
Excess cortisol
129
What effect does Cushing's syndrome have on protein and how does this manifest?
```
Protein is lost:
- Myopathy -> Wasting
- Osteoporosis -> Fractures
- Thin skin
> Striae
> Bruising
```
130
What does the excess mineralocorticoid cause in Cushing's?
Hypertension
| Oedema
131
What does the excess androgen cause in Cushing's?
Virilism
Hirsutism
Acne
Oligo/Amenorrhoea
132
What distinguishes Cushing's from obesity?
```
Thin skin
Proximal myopathy
Frontal balding in women
Chemosis
Osteoporosis
```
133
What are some screening tests for Cushing's?
```
Overnight 1mg PO dexamethasone suppression:
- Cortisol Normal
- Cortisol >100nmol/L -> Abnormal
Urine free cortisol (24hr):
- Total
```
134
What is the definitive test for diagnosing Cushing's?
Two day 2mg/day low dose DST:
| - Cortisol No Cushing's
135
What can cause an ectopic production of ACTH?
Thymus
Small-cell lung cancer
Pancreas
136
How is pituitary Cushing's (Cushing's disease) treated?
Hypophysectomy + External radiotherapy if it recurs
137
How is adrenal Cushing's treated?
Adrenalectomy
138
How is ectopic Cushing's treated?
Remove source
OR
Bilateral adrenalectomy
139
What is the drug treatment for Cushing's and when is it used?
Metyrapone:
- If other treatments fail
- While waiting for radiotherapy to work
140
How does pan-hypopituitarism present?
```
Growth failure
Hypothyroidism
Hypogonadism
Hypoadrenal
Diabetes Insipidus
```
141
What local brain tumours can cause hypopituitarism?
Astrocytoma
Meningioma
Glioma
142
What granulomatous disease can cause hypopituitarism?
TB
Histiocytosis X
Sarcoidosis
143
What effects does growth hormone have in adults?
```
Reduces abdominal fat
Increases:
- Muscle mass
- Strength
- Stamina
Improves cardiac function
Reduces cholesterol and LDL
Increases bone density
```
144
What are some risks of testosterone replacement?
Prostate enlargement
Polycythaemia
Hepatitis
145
What dose the following stand for in terms of a familial presentation of cranial diabetes insipidus DIDMOAD?
DI
DM
Optic Atrophy
Deaf
146
How is diabetes insipidus diagnosed?
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
How can DI be treated?
```
Desmospray:
- Nasally -> 10-60micrograms daily
Oral desmopressin:
- 100-1000micrograms daily
Sublingual desmopressin:
- 60-360micrograms daily
Desmopressin injection:
- IM -> 1-2micrograms daily
```
