Endocrinology

Question 1

What occurs with Thyroid Hormones in normal aging?

Answer 1

Decreased T4 secretion (but decreased clearance), so NL
Decreased or NL T3 (due to decreased peripheral conversion)
TSH is NL or increased

Question 2

Most common cause of hypothyroidism in older adults?

Answer 2

Hashimoto disease (chronic autoimmune thyroiditis)

Question 3

How do you diagnose primary hypothyroidism?

Answer 3

High TSH, low T4

Question 4

What is subclinical hypothyroidism?

Answer 4

TSH >4.5 with normal T4

Question 5

When should you treat subclinical hypothyroidism?

Answer 5

In older adults iwth TSH >10 (symptom benefit and possibly lower ischemic heart disease)

Question 6

What do TSH levels do during nonthyroid illness?

Answer 6

low then transiently increase during the recovery phase

Question 7

What do T3 and T4 levels do during acute nonthyroid illness?

Answer 7

low T3 (with normal TSH) or
Low T4 (with normal TSH)

Question 8

Starting doses for synthroid

Answer 8

25 mcg/day or 50 mcg/day (if no e/o CAD)

Question 9

What should occur before treating severe hypothyroidism?

Answer 9

testing for adrenal insufficiency (for stress dose steroids)

Question 10

What is the target TSH level for older adults?

Answer 10

4-7 mIU/L

Question 11

What is the most common cause of hyperthyroidism in older adults?

Answer 11

Graves disease

Question 12

How may older adults present with hyperthyroidism?

Answer 12

Apathetic thyrotoxicosis (depression, inactivity, lethargy, withdrawn behavior with anorexia, weight loss, constipation, muscle weakness or cardiac symptoms)

Question 13

What is T3 toxicosis associated with?

Answer 13

toxic adenomas or toxic multinodular goiters (more common in elderly)

Question 14

What is the next step for someone with hyperthyroidism?

Answer 14

Radioactive iodine uptake and scanning

Question 15

When should hyperthyroidism be treated?

Answer 15

In all adults >60 with TSH <0.1 mIU/L OR if TSH 0.1-0.4 with symptoms or comorbidities like heart disease or osteoporosis

Question 16

When should a thyroid nodule be FNA’s?

Answer 16

if cold on RAI or >1 cm in size with high risk features, >1.5cm in size for low risk features or >2cm in size for very low risk features

Question 17

When will you see high phos with high calcium?

Answer 17

Local osteolytic hypercalcemia

Question 18

What are the indications for surgery for primary hyperparathyroidism?

Answer 18

symptomatic hyperparathyroidism OR asymptomatic with:
-Calcium >1 mg/dL above normal
-CrCl <60
-BMD less than -2.5
-Vertebral fracture
-Nephrolithiasis
-24-hour urine calcium >400 mg/day with increased stone risk
-Neurocognitive or neuropsychiatric symptoms (possibly)

Question 19

What is an alternate to those who cannot get parathyroid surgery?

Answer 19

Cinacalcet (but does not increase BMD so may need to use bisphosphonate)

Question 20

What is the next step if abnormally low Testosterone?

Answer 20

LH and FSH (if these are low, check a prolactin)

Question 21

When is it reasonable to replace testosterone?

Answer 21

with levels <200 ng/dL and symptoms