ENDO-HYPER Flashcards
What is the MCC of Hyperthyroidism
autoimmune- Graves disease
1] Toxic nodular goiter (single or multinodular),
2] Thyroiditis (subacute, painless, postpartum),
3] TSH producing adenoma (rare)
Pt c/o Weight loss, insomnia, anxiety, irritability, heat intolerance, palpitations, tremors, frequent bowel movements, muscle weakness, hair loss, oily skin, amenorrhea
Hyperthyroidism
PT has the following on PE. What is DX? tachycardia, diaphoresis-sweating diffuse palpable goiter, thyroid bruit, fine tremor, opthalmopathy (proptosis, lid retraction, chemosis-edema in eye
Hyperthyroidism vitals
why the thyroid bruit occurs in Hyperthyroidism?
increased blood flow in goiter
What are the cardivacular findings in Hyperthyroidism
sinus tachycardia,
systolic flow murmurs,
atrial fibrillation,
prominent API-arterial pulse pressure
Who is more comonly affected by Graves disease
Women 20-40, FH, autoimmune/thyroid disease common
autoantibodies to TSH receptor (TRAb, TSHRAb, TSI, TBII), Abs bind and activate TSH receptors
stimulate thyroid hormone production and thyroid growth
Describe the laboratory findings of Graves disease
low TSH, HIGH T4/ T3, positive thyroid antibodies
What is the unique clinical presentation of Graves disease
Opthalmopathy- not found in other causes of hyperthyroidism.
2% of all cases
Describe Infiltrative Opthalmopathy
Inflammation of the extraocular muscles, connective and adipose tissue
Smoking makes worse
What is the management for Graves disease
1] Refer to endocrinology,
2] Anti-thyroid meds (thionamides),
3] TSH, FT4, FT3 monitored after 3-4 weeks and then q 2-3 months.
Goal is euthyroidism.
Describe the Anti-thyroid meds
1] propylthiouracil (PTU) and methimazole: inhibit thyroid hormone synthesis,
2] Methimazole preferred (once daily dosing, more rapid efficacy, lower incidence of side effects),
3] Treatment can continue 12-24 months with possibility of remission (20-30%)
What are the side effects of methimazole
agranulocytosis/neutropenia.
baseline CBC w/diff prior to tx and monitor during tx.
Neutropenia-first couple months and higher dose of therapy increases likelihood of ADE.
What are the side effects of PTU
hepatoxicity, agranulocytosis
monitor LFT’s, CBC
Describe definitive treatment for Graves disease
euthyroid with medication(3-8 weeks),
proceed with radioactive iodine ablation (RAI)
permanent solution to hyperthyroidism,
permanent hypothyroidism- need lifelong thyroid replacement
Usually two part series- radioactive iodine uptake and scan then nuclear med radiologist uses that information to determine appropriate dose of iodine for radioactive iodine ablation (patient returns 1-2 days later for ablation)
Describe the use of beta blockers for Graves disease
symptomatic relief (tachycardia, anxiety, tremulousness, heat intolerance)
How does atrial fib due to hyperthyroidism
because too much thyroid hormone irritates the heart
How does CHF due to hyperthyroidism
increased HR, palpitations,
causing ventricular hypertrophy-to thick to expand, less vol. less out
decreased cardiac output= SVxHR
How does Bone loss due to hyperthyroidism
thyroid hormone increases bone turnover= more osteoclast activity
Describe the thyroid storm
Rare, life-threatening condition (Mortality rate- 20-30%) severe hyperthyroidism with cardiac manifestations , untreated hyperthyroidism;
Eitiology- acute event (surgery, trauma, infection, acute iodine load, childbirth). Body overdrive to fix problme
PT tachycardia, cardiac arrhythmia, hyperpyrexia, n/v/d; may progress to delerium, psychosis, comaDescribe the clinical features of thyroid storm
S/S of THYROID STORM
What is 2nd MC after Graves? Who? DX tool? TX
Nodular areas hypersensitive to TSH stimulation,
resulting in nodules excessive amounts of thyroxine,
Who? Elderly
DX-Thyroid uptake scan can determine presence of “hot”- iodine uptake
beta blockers, thionamides
permanent solution -adioactive iodine ablation(RAI), surgery
Describe the thyroid scintigraphy (uptake and scan)
Diff btwn throiditis and hyperthyoidism
an iodine uptake test- a scan (imaging) with a gamma camera.-returns 24 hours later to have the level of radioiodine, metal bar measures the radioactivity emitting from the thyroid.
PT c/o-Fever, fatigue and lethargy with mild, 2-8 weeks post URI
PE- + Thyroid is tender and diffusely enlarged
Subacute Thyroiditis-viral infection or postviral inflammatory process
transient hyperthyroidism initially, followed by transient hypothyroidism,
self-limited non suppurative inflammation with abrupt
onset of pain in the thyroid that radiates to the ear, jaw and neck,
How do you treat of Subacute Thyroiditis
symptomatic: NSAID, prednisone;
Full recovery is common
PT c/o-Fever, fatigue and lethargy with mild, 2-8 weeks post URI
PE- + Thyroid gland is not painful or tender
What is next step in TX
Painless/Silent thyroiditis
Transient mild hyperthyroidism, sometimes followed by hypothyroidism, then recovery
TX-symptomatic (beta blocker, short course of thyroxine)
What are the lab findings of Thyroiditis
Labs often indicate low TSH, elevated T4, T3 can be normal or slightly elevated, and
elevated ESR
Describe Postpartum thyroiditis
A variant form of Hashimoto’s thyroiditis (+ TPOAb), one year of parturition-mistaken for post partum depression; Typically hyperthyroid phase followed by hypothyroidism
NO tx needed
symptomatic relief during hyper/hypo phases (beta blocker, thyroxine);
Most women recover completely, but 30% have permanent hypothyroidism ***
Describe incidence rate of thyroid nodules
90% are benign adenomas/cysts;
50% of the population between ages 30-60;
10% are lesions low grade malignancy
agressively thyroid cancer-RARE
What are solitary thyroid nodules? What are next steps?
benign adenomas with hypofunction;
endocrinologist with
1] Thyroid ultrasounds should be performed on all patients with suspected nodule,-size, consistency, characteristics, and number of nodules
2] Thyroid uptake/scan
Ultrasound guided fine needle aspiration (FNA) biopsy results management
1] If benign adenoma with nml TFT’s , no tx necessary, annual ultrasounds,
2] If cystic aspirate; repeat 6-12 months,
3] If FNA cytology positive for thyroid cancer: begin aggressive treatment
MC malignant neoplasms of the endocrine system;
Thyroid Carcinoma
Describe Thyroid Carcinoma risk factors. What is key to early dx?
history of irradiation to the head and neck,
FH
1] Routine screening with ultrasound and FNA thyroid nodules is key
2] Aggressive treatment to prevent early metastasis
What findings solid nodules with increase in size from prior study, presence of microcalcifications mean?
Thyroid Carcinoma
List the Classification of Thyroid Carcinoma
1] Papillary-MC,-Most common and most benign, 80% of all thyroid cancers are papillary type
2] Follicular,
3] Medullary,
4] Anaplastic-
cause, prognosis, risk tx of Papillary Thyroid Carcinoma
ETI-genetic, radiation exposure
Prognosis- Positive lymph nodes of the neck in > 50% cases-Distant spread uncommon. near 100% cure for small lesions in young patients
distant metastasis-inc mortality
What is the treatment of Papillary Thyroid Carcinoma
total thyroidectomy,
followed by RAI ablation,
TSH suppression therapy
Describe the incidence rate of Follicular Thyroid Carcinoma
second most common, Peak onset ages 40-60, Occurs in females > males (3:1), Rarely associated with radiation exposure
Describe Medullary Thyroid Carcinoma
Neuroendocrine tumor that produces calcitonin
3-5% of all thyroid cancers; Females affected more than males; Not associated with radiation exposure
<p>Describe the incidence rate of Anaplastic Thyroid Carcinoma</p>
1% of all thyroid carcinomas; Males age 60
Prognoisis- high mortality rate 5 year survival rate around 5%
