Mehlman IM/FM 16 + Im consp. THYROID 03-03 (2) Flashcards
thyroid cancer. FIRST step?
PALPATE thyroid
thyroid cancer. first step - you do palpation. NEXT BEST step?
TSH
thyroid cancer. Nodule + TSH normal/high (ie euthyroid or hypothyroid) –> what to do?
ULTRASOUND over FNA
thyroid cancer. Nodule + TSH normal/high. UG vs FNA answer?
If both listed –> UG
If Ug not listed –> FNA
thyroid cancer. Nodule + TSH low (ie hyperthyroid) –> ?
Radioiodine uptake scan (NOT UG)
Since carcinomas are non-secretory of thyroid hormone, if a patient is hyperthyroid, we’re not concerned about carcinoma, which is why we don’t go the ultrasound then FNA route. We just do uptake to better see
if the patient’s etiology for hyperthyroidism is Graves (diffuse), toxic adenoma (single nodular uptake), or toxic multinodular goiter (multifocal nodular uptake).
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thyroid cancer.
NO NODULE + TSH low (aka hyperthyroidism) –> ?
DO ULTRASOUND (uptake scan is wrong)
annoying, bet taip yra. jeigu hyperthyroidism and nodule, tada uptake scan
TSH is screening for everyone except….
Pregnant
What can be ordered after TSH?
T3 and T4, but usmle often omits this
Screening for pregnancy?
Free-T4
What is most diagnostic/accurate for everyone?
Free T4
2CK hypothyroidism presentation. mood + treatment?
Low mood (dysthymia) –> mood improve with administration of thyroid hormone
2CK hypothyroidism presentation. muscles + what lab?
proximal muscle weakness: difficulty getting up from chair unassisted +/- increased CK
2CK hypothyroidism presentation. cholesterol?
Increased total cholesterol, eg 300mg/dl
2CK hypothyroidism presentation. hepatic?
incr. AST
2CK hypothyroidism presentation. heart?
BRADYCARDIA 55-60 k/min.
nera taip, kad cia nenormalu, nes yra kas turi reta dazni, bet prie hypothyroid bus brady
If patient is pscyh. you have two options for initian: check suicidal ideation vs TSH?
in pshych: check suicidal ideation FIRST
do simple investigation before ordering investigation
If patient is not pscyh and suspect hypothyroidism, what investigation?
TSH is correct for hypothyroidism initial screening
Hashimoto? Anti-microsomal (aka anti-thyroperoxidase) + anti-thyroglobulin antibodies.
T3 low, T4 low, TSH high
iodine uptake decreased or patchy
Subclinical hypothyroidism?
normal T3, normal T4, TSH high
uptake normal/reduced
Euthyroid sick syndrome?
decr T3, high reverse T3, normal T4, normal TSH
Graves? antibody is called thyroid- stimulating immunoglobulin (TSI).
high T3, high T4, TSH low
uptake diffuse
Toxic multinodular goiter?
high T3, high T4, TSH low
high multifocal/multinodular uptake
Toxic adenoma?
high T3, high T4, TSH low
high uptake isolated to one nodule
Factitious thyrotoxicosis with levothyroixine (T4)?
high T3, high T4, TSH low
low uptake
Factitious thyrotoxicosis with triiodothyronine (T3)?
high T3, low T4, TSH low
low uptake
T4 is converted to T3 peripherally, but not the other way around
Subacute thyroiditis (subacute granulomatous thyroiditis; DeQuervain)?
can be hypo/hyper
Key: uptake is decreased always no matter what
So, if patient is hyper, choose high T3, T4, low TSH, DECREASED UPTAKE.
Is 16 lecture yra apie depresija dar dalis, tai cia kortose nera.
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Hashimoto assoc. with autoimmune diseases
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Hashimoto antibodies?
anti-microsomal (aka anti TPO) and anti-thyroglobulin antibodies
Hashimoto Tx?
levothyroxine or trijodtironine
Graves antibodies?
antibodies against TSH receptors=thyroid stimulating imunoglobulin (TSI)
Graves Tx?
thionamides
Thyroid storm what is it?
acute exacerbation of graves in case of stress –> severely increased production of thyroid hormone
Thyroid storm Tx tetrad?
BAB - propranolol
PTU
potassium iodide
Glucocorticoids (eg hydrocortisone, to decr. peripheral T4 -> T3 conversion and improve vasomotor stability)
wolf-chaikof? definition and Tx?
transient decr. of thyroid synthesis in the setting of acute incr. in iodine exposure.
Tx - potassium iodine
Factitious thyrotoxicosis. pacient will be lets say pharmacist - has access to hormone
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Factitious: Q will give hyperthyroid patient with small, non-palpable thyroid gland
(atrophic due to suppressed TSH).
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drug in first thimester?
PTU
Methimazole is teratogen in 1st trimester
hepati failure which drug?
PTU
Radioiodine ablation adverse?3
Permanent hypothyroidism
Worsening ophthalmopathy
Possible radiation side effect
Surgery for graves adverse?3
permanent hypothyroidism
Risk of laryngeal reccurent nerve damage
Risk of hypoparathyroidism
anti-thyroid drug+fever+sore throat –>?
agranulocytosis
anti-thyroid drug+fever+sore throat –>agranulocytosis –> what to do?
discontinue drug
measure WBC
If WCB < 1000 = dicontinue permanently
Ir WBC > 1500 = drug toxicity is unlikely cause of sore throat
anti-thyroid induced agranulocytosis. management?3
discontinue drug
broad spectrum abs (covering pseudomonas)
granulocyte stimulating factors
Graves. antithyroid drugs. indications table?4
mild hyperthyroidism
Older age with limited life expectancy
preparation for radioactive iodine or thyroidectomy
Pregnacy (PTU in first trimester)
Graves. radioactive iodine. indications table?2
moderate to severe hyperthyroidism with/without mild ophthalmopathy
Patient preference in mild hyperthyroidism
Graves. thyroidectomy. indication table 6?
very large goiter
Suspicion of thyroid cancer
coexsisting primary hyperparathyroidism
pregnant patients who cannot tolerate thionamides
Severe ophthalmopathy
Retrosternal goiter with obstructive symptoms
Graves + worsening ophthalmo –> Tx?
radioactive iodine
definitive Tx for severe ophthalmopathy?
surgery
what cannot do if severe ophthalmopathy?
dont give radioactive iodine (its contraindicated)
Oral prednisolone specifically for Tx of what? exophthalmos (anti-thyroid drugs are not effective!!!!!)
exophthalmos (anti-thyroid drugs are not effective!!!!!)
Mehl. observation: if patient euthyroid/hypothyroid with thyroid nodule –> what next step?
UG - if both ug and fna listed
If ug not listed -> choose fna
thryoid cancer.
If jeigu low TSH (hyperthyroidism) + nodule –> next step?
uptake scan (ug wrong)
Subclinical hypothyroidism, when Tx?
Most patients with subclinical do not need to be treated.
Don’t treat unless TSH >10, patient is pregger, or anti-Hashimoto Abs are +.
what drugs induce neutropenia/agranulocytosis?
PTU and methimazol
Tx of thyroid storm on USMLE is tetrad of:???
1) PTU,
2) propranolol,
3) steroids, and
4) potassium iodide (shuts off thyroid gland due to Wolff-Chaikoff effect).
Drug-induced thyroiditis. what 2 drugs on usmle?
lithium and amiodarone
Will usually present on USMLE as painless hypothyroidism in patient being treated for bipolar disorder (lithium) or started on new anti-arrhythmic (amiodarone). Dx?
Drug-induced thyroiditis
Drug induced thyroiditis. uptake?
Will present with decr. 131I uptake, where inflammation of the gland can sometimes cause leakage of thyroid hormone into the blood, but the gland itself is not demonstrating increased production of hormone.
Euthyroid sick syndrome. what viggnetes?
Vignette will give patient being weaned from a ventilator, or someone who’s had recent major trauma or surgery.
Euthyroid sick syndrome - one of the most “underrated” thyroid diagnoses. usmle asks about this Dx
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Hashimoto thyroiditis inc risk for what?
incr. risk of non-Hodgkin lymphoma (e.g., primary CNS lymphoma).
Autoimmune diseases and immunodeficiencies to together. Hashimoto = autoimmune destruction.
thyroid storm can also cause adrenal crisis (i.e., acute ̄ in blood pressure due to rapid consumption of cortisol), especially in those with concurrent adrenal insufficiency taking exogenous steroids. Tx?
Tx for the low BP is IV glucocorticoid (i.e., hydrocortisone or methylprednisolone).
deQuervain thyroiditis. pain?
viral infection -> painful/tender thyroid
deQuervain thyroiditis. inflammation of the thyroid gland, which causes the spacing between the cells to increase slightly, allowing for the release of pre-formed thyroid hormone into the blood.
The gland is not over-producing thyroid hormone. This is why uptake is not increased.
deQuervain thyroiditis = hypo- or hyperthyroid. The key detail you need to know is that uptake is always decreased even if the patient is hyper.
DeQuervain vignettes will almost always be given as hyperthyroidism because the USMLE wants to specifically assess that you know uptake is decreased.
If they give you hypo-, of course you’ll select decreased for uptake.
Decreased uptake applies to all thyroiditis conditions (i.e, deQuervain, drug- induced, and postpartum).
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for deQuervain = Viral infections are often asymptomatic, so most deQuervain vignettes will not mention the viral infection.
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Incr. creatine kinase (hypothyroid myopathy) - usmle duoda sita su hipotiroidizmu.
UW. A 34-year-old woman comes to the office due to fullness in her neck after noticing a difference in how jewelry rests around her neck as compared to before. The patient has no other symptoms. She has no medical issues and takes no medications. Family history includes thyroid surgery for an enlarged thyroid gland in her mother. Examination reveals a 1.4-cm firm, nontender, mobile nodule in her left thyroid lobe. The remainder of the physical examination is unremarkable. Laboratory evaluation shows serum TSH of 0.25 µU/mL, serum total thyroxine (T4) of 10 µg/dL, and serum triiodothyronine (T3) of 176 ng/dL. A thyroid ultrasound reveals a 1.4-cm left thyroid nodule with smooth margins and no microcalcifications or internal vascularity. Which of the following is the most appropriate next step?
RADIONUCLIDE THYROID SCAN
- A hypofunctioning (“cold”) nodule (decreased isotope uptake compared to surrounding tissue) is associated with a higher risk of cancer.
- A hyperfunctioning (“hot”) nodule (increased isotope uptake in the nodule with decreased surrounding uptake) is associated with a low cancer risk; therefore, FNA is not necessary.
