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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
Which medication is first line for hyperthyroidism? Why?
Methimazole PTU has risk of serious liver injury
26
In what case is PTU first line treatment?
In the 1st trimester of pregnancy and during lactation
27
What is the first test for at new thyroid nodule found on exam?
TSH
28
Benign causes of thyroid nodules?
``` Adenomas Cyst Hashimotos Subacute thyroiditis Riedels struma ```
29
Malignant causes of thyroid nodules?
Papillary carcinoma | Follicular carcinoma
30
Compare Hashimoto’s thyroiditis with subacute thyroiditis
Chronic v. Acute Lymphocytic v. Inflammatory (viral) Painless v. Painful, fever Hyper to hypothyroidism v. Hyperthyroid to transient hypothyroidism
31
How does the thyroid change during pregnancy?
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
What is the TSH goal in pregnancy?
< 3.0
33
How should levothyroxine dosing change in women with hypothyroidism who then become pregnant?
Increase dose by 25-50% during pregnancy
34
Should women with gestational hyperthyroidism receive anti thyroid meds?
Not indicated | NO radioactive iodine scanning during pregnancy
35
What treatment should pregnant women with Graves get in the first trimester?
PTU
36
How to monitor and treat post partum thyroiditis?
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
List some causes of hypercalcemia
``` 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
What medications can cause hypercalcemia?
Thiazides Lithium Calcium antacids (Milk alkali syndrome) Vit A intoxication
39
What endocrine disorders can lead to hypercalcemia?
Hyperthyroid Hyperparathyroidism Acromegaly Pheochromocytoma
40
Presentation of hyperparathyroidism
Bones, stones, groans, psychiatric overtones
41
Treatment of hyperparathyroidism?
Locate and remove tumor
42
Treatment for hypoparathyroidism?
Calcium and vitamin D Very uncommon
43
Causes of primary hyperparathyroidism?
Usually from single adenoma Sometimes multiple benign tumors Rarely cancer Usually asymptomatic at time of diagnosis Remove adenoma or overactive glands
44
Causes of secondary hyperparathyroidism?
Vit D deficiency CKD Manage underlying cause
45
How to diagnose prolactinoma?
Prolactin >200 MRI with contrast Check visual fields Pregnancy test Thyroid function
46
Name 4 things the pituitary gland secretes and symptoms of hyper-secretion?
Prolactin- amenorrhea, galactorrhea Growth hormone- gigantism, acromegaly Corticotropin- Cushings TSH- Hyperthyroidism
47
How to evaluate a sellar mass?
MRI with gadolinium CT (can see calcification in craniopharyngioma/meningioma) PET scan
48
Differential diagnosis of a sellar mass?
Benign: Pituitary adenoma Craniopharyngioma Meningioma Malignant: Primary tumors- germ cell, sarcoma, chordoma, carcinoma Metastatic- lung, breast
49
What are the primary features of Cushing’s syndrome?
``` Central obesity Ecchymoses Plethora Proximal weakness Osteopenia/porosis Hypertension WBC >11 Purple striae >1 cm ```
50
Other features of Cushing’s syndrome (not primary)?
Myopathy Hirsutism Opportunistic infections Loss of libido
51
Who is at increased risk of developing Cushing’s syndrome?
People with: Diabetes, Obesity, HTN, Osteoporosis 24-40 years old
52
What is step one of diagnosing Cushing’s syndrome?
Confirm the elevated cortisol - AM cortisol - 24 hour urine - Midnight salivary cortisol
53
What is the second step of diagnosing Cushing’s syndrome?
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
Clinical presentation of Addison’s disease?
``` Hyperpigmentation Low blood pressure Weight loss Nausea, Vomiting Muscle cramps Irregular menses Salt craving Malaise, Fatigue ```
55
Primary and secondary causes of Addison’s disease?
Primary: Atrophy/destruction of adrenal glands Secondary: Decreased ACTH from pituitary
56
What are the two main changes seen in Addison’s disease?
Decreased Cortisol and aldosterone
57
How to diagnose Addison’s disease?
``` Serum electrolytes Blood glucose CBC ACTH stimulation test CT or MRI of adrenals ```
58
How to treat Addison’s disease?
Replace cortisol and aldosterone
59
Thyroid hot nodule meaning and management?
Low TSH, radionucleotide uptake scan shows a hyperactive nodule Radioiodine ablation, Surgery, Medication
60
Thyroid Cold nodule meaning and management?
Low TSH, radionucleotide uptake shows hypoactive nodule Review Ultrasound results for suspicious features- management depends on US results
61
If a thyroid nodule has suspicious features what is the management?
If <1 cm repeat US in 6-9 months If >=1 cm get FNA
62
What are suspicious features on a thyroid ultrasound?
``` Irregular margins Microcalcifications Nodule taller than wide Extra thyroid extension Cervical lymphadenopathy Disrupted rim calcification ```
63
Management of Purely cystic thyroid nodule
Aspiration if large cyst | No FNA
64
General principles of thyroid nodule management if no suspicious features?
Small- repeat in 12-24 months Large- FNA *Size and management depends specifically on US findings (see AAFP thyroid nodules flow chart)
65
If TSH is abnormal, what is the next step?
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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