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01 Family Medicine > Endocrine > Flashcards

Endocrine Flashcards

AAFP Board Review lecture: Endocrine

1
Q

Define subclinical hypothyroidism

A

Elevated TSH
Normal T4
Asymptomatic

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2
Q

Define Overt hypothyroidism

A

Elevated TSH
Low T4
+/- symptoms

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3
Q

Define subclinical hyperthyroidism

A

Low TSH
Normal T4
Asymptomatic

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4
Q

Define Overt hyperthyroidism

A

Low TSH
Elevated T4
+/- symptoms

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5
Q

Risk factors for elevated TSH (hypothyroid)

A

female, increased age, white,

T1 DM, Downs syndrome

hx of hyperthyroid, goiter, radiation to neck, amiodarone use

Family hx of thyroid disease

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6
Q

Risk factors for low TSH (hyperthyroid)

A

female, increased age, black, low iodine intake, fam hx, medications (amiodarone)

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7
Q

Who should get screened for thyroid dysfunction and how?

A

Screen those with symptoms of thyroid dysfunction

Insufficient evidence to screen asymptomatic non pregnant adults (no benefit in blood pressure, BMI, bone density or lipids)

Order TSH

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8
Q

What threshold of TSH does not require repeat testing and would likely initiate treatment?

A

If greater than 10 or less than 0.1

No clear consensus on upper and lower limits of normal inbetween 0.1 and 10

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9
Q

What is the most common cause of hypothyroidism in the US?

A

Chronic autoimmune (Hashimoto) thyroiditis

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10
Q

What are common causes of hyperthyroidism?

A

Graves disease, Hashimoto thyroiditis, functional nodules,
Metastatic thyroid cancer,
Hyperemisis gravidarum

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11
Q

First test to get for any thyroid issue?

A

TSH

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12
Q

Signs and symptoms of hypothyroidism?

A

Slow DTRs, hyperlipidemia

Dry skin, hair loss, constipation, weight gain, cold intolerance, bradycardia, macroglossia etc.

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13
Q

How to diagnose hypothyroidism?

A

History, PE, TSH

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14
Q

Should you order T4/T3, antibodies to diagnose hypothyroidism?

A

Not necessary

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15
Q

What are some surrogate markers of hypothyroidism?

A

High CPK, LDL, triglycerides
Proteinuria
Normocytic anemia

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16
Q

How to treat hypothyroid? Starting dose?

A

Levothyroxine (T4)

  • 1.6 mcg/kg/day
  • (elderly start at 1 mcg/kg/day)

Take on empty stomach, wait 30 minutes before eating

Check after 6 weeks and adjust dose

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17
Q

Is using desiccated thyroid (Armour) or combination of T3/T4 better than T4 (levothyroxine)?

A

Armour- poorer quality control

T3/T4 not superior to T4 alone

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18
Q

What are the risks of Supratherapeutic treatment of hypothyroidism?

A

Can develop osteoporosis, afib

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19
Q

What medications have interactions with thyroid treatment?

A

Iron, sucralfate, cholestyramine, antacids, anticonvulsants, grapefruit, amiodarone, lithium, SSRIs, retinoids

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20
Q

In treating hypothyroidism when should your goal be TSH < 2.5?

A

If the TSH is WNL but the patient is still having symptoms

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21
Q

Which medications decrease conversion of T4 to T3?

A

OCPs, Steroids, Chemotherapy, Lithium, SSRIs, Phenytoin, Iodine contrast agents, Theophylline, Beta blockers, Fluoride, opiates, Estrogen

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22
Q

What non medication factors decrease conversion of T4 to T3?

A

Stress, aging, alcohol, fasting, radiation, low ferritin, pesticides, soy, hemochromatosis, smoking, kidney disease

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23
Q

How to diagnose hyperthyroidism?

A 
History, PE
TSH, T4/T3
Radioactive uptake scan
CBC
Consider ESR, US, antibodies
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24
Q

Treatment for hyperthyroidism?

A

Radioactive iodine

Methimazole, PTU, Beta blockers

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25
Q

Which medication is first line for hyperthyroidism? Why?

A

Methimazole

PTU has risk of serious liver injury

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26
Q

In what case is PTU first line treatment?

A

In the 1st trimester of pregnancy and during lactation

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27
Q

What is the first test for at new thyroid nodule found on exam?

A

TSH

28
Q

Benign causes of thyroid nodules?

A 
Adenomas
Cyst
Hashimotos
Subacute thyroiditis
Riedels struma
29
Q

Malignant causes of thyroid nodules?

A

Papillary carcinoma

Follicular carcinoma

30
Q

Compare Hashimoto’s thyroiditis with subacute thyroiditis

A

Chronic v. Acute

Lymphocytic v. Inflammatory (viral)

Painless v. Painful, fever

Hyper to hypothyroidism v. Hyperthyroid to transient hypothyroidism

31
Q

How does the thyroid change during pregnancy?

A

Gland size can increase by 10%

50% inc in hormone production

10% of pregnant women in 1st trimester will be positive for TPO or thyroglobulin antibodies

  • 16% hypothyroidism
  • 30-50%will develop post partum thyroiditis
32
Q

What is the TSH goal in pregnancy?

A

< 3.0

33
Q

How should levothyroxine dosing change in women with hypothyroidism who then become pregnant?

A

Increase dose by 25-50% during pregnancy

34
Q

Should women with gestational hyperthyroidism receive anti thyroid meds?

A

Not indicated

NO radioactive iodine scanning during pregnancy

35
Q

What treatment should pregnant women with Graves get in the first trimester?

A

PTU

36
Q

How to monitor and treat post partum thyroiditis?

A

During toxic phase no anti thyroid meds

Monitor TSH q 2 months after toxic phase to monitor for hypothyroidism

6-12 months after starting levothyroxine try to wean off medication

37
Q

List some causes of hypercalcemia

A 
Hyperparathyroidism 
Vitamin D intoxication
Granulomatous disease
Hodgkin’s lymphoma 
Malignancy (PTHrP, local osteolysis)
Familial hypocalciuric hypercalcemia 
Medications
Other endocrine disorders
Immobilization (pagets disease, kids)
Recovery phase of rhabdo
38
Q

What medications can cause hypercalcemia?

A

Thiazides
Lithium
Calcium antacids (Milk alkali syndrome)
Vit A intoxication

39
Q

What endocrine disorders can lead to hypercalcemia?

A

Hyperthyroid
Hyperparathyroidism
Acromegaly
Pheochromocytoma

40
Q

Presentation of hyperparathyroidism

A

Bones, stones, groans, psychiatric overtones

41
Q

Treatment of hyperparathyroidism?

A

Locate and remove tumor

42
Q

Treatment for hypoparathyroidism?

A

Calcium and vitamin D

Very uncommon

43
Q

Causes of primary hyperparathyroidism?

A

Usually from single adenoma
Sometimes multiple benign tumors
Rarely cancer

Usually asymptomatic at time of diagnosis

Remove adenoma or overactive glands

44
Q

Causes of secondary hyperparathyroidism?

A

Vit D deficiency

CKD

Manage underlying cause

45
Q

How to diagnose prolactinoma?

A

Prolactin >200
MRI with contrast

Check visual fields
Pregnancy test
Thyroid function

46
Q

Name 4 things the pituitary gland secretes and symptoms of hyper-secretion?

A

Prolactin- amenorrhea, galactorrhea

Growth hormone- gigantism, acromegaly

Corticotropin- Cushings

TSH- Hyperthyroidism

47
Q

How to evaluate a sellar mass?

A

MRI with gadolinium

CT (can see calcification in craniopharyngioma/meningioma)

PET scan

48
Q

Differential diagnosis of a sellar mass?

A

Benign:
Pituitary adenoma
Craniopharyngioma
Meningioma

Malignant:
Primary tumors- germ cell, sarcoma, chordoma, carcinoma
Metastatic- lung, breast

49
Q

What are the primary features of Cushing’s syndrome?

A 
Central obesity
Ecchymoses
Plethora
Proximal weakness
Osteopenia/porosis 
Hypertension
WBC >11
Purple striae >1 cm
50
Q

Other features of Cushing’s syndrome (not primary)?

A

Myopathy
Hirsutism
Opportunistic infections
Loss of libido

51
Q

Who is at increased risk of developing Cushing’s syndrome?

A

People with:
Diabetes, Obesity, HTN, Osteoporosis
24-40 years old

52
Q

What is step one of diagnosing Cushing’s syndrome?

A

Confirm the elevated cortisol

  • AM cortisol
  • 24 hour urine
  • Midnight salivary cortisol
53
Q

What is the second step of diagnosing Cushing’s syndrome?

A

Dexamethasone suppression test

Dex acts like cortisol -> decreases ACTH release from pituitary -> adrenals make less cortisol

If Cushings Dex does not affect adrenal cortisol production

54
Q

Clinical presentation of Addison’s disease?

A 
Hyperpigmentation
Low blood pressure
Weight loss
Nausea, Vomiting
Muscle cramps
Irregular menses
Salt craving
Malaise, Fatigue
55
Q

Primary and secondary causes of Addison’s disease?

A

Primary: Atrophy/destruction of adrenal glands

Secondary:
Decreased ACTH from pituitary

56
Q

What are the two main changes seen in Addison’s disease?

A

Decreased Cortisol and aldosterone

57
Q

How to diagnose Addison’s disease?

A 
Serum electrolytes
Blood glucose
CBC
ACTH stimulation test
CT or MRI of adrenals
58
Q

How to treat Addison’s disease?

A

Replace cortisol and aldosterone

59
Q

Thyroid hot nodule meaning and management?

A

Low TSH, radionucleotide uptake scan shows a hyperactive nodule

Radioiodine ablation,
Surgery, Medication

60
Q

Thyroid Cold nodule meaning and management?

A

Low TSH, radionucleotide uptake shows hypoactive nodule

Review Ultrasound results for suspicious features- management depends on US results

61
Q

If a thyroid nodule has suspicious features what is the management?

A

If <1 cm repeat US in 6-9 months

If >=1 cm get FNA

62
Q

What are suspicious features on a thyroid ultrasound?

A 
Irregular margins
Microcalcifications
Nodule taller than wide
Extra thyroid extension
Cervical lymphadenopathy 
Disrupted rim calcification
63
Q

Management of Purely cystic thyroid nodule

A

Aspiration if large cyst

No FNA

64
Q

General principles of thyroid nodule management if no suspicious features?

A

Small- repeat in 12-24 months

Large- FNA

*Size and management depends specifically on US findings (see AAFP thyroid nodules flow chart)

65
Q

If TSH is abnormal, what is the next step?

A

If TSH is abnormal repeat multiple tests over 3-6 months. Follow up with T4 testing if persistently abnormal

*TSH affected by illness and medications

01 Family Medicine (16 decks)

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