Mehlman IM/FM 16 + Im consp. THYROID 04-14 (3) Flashcards by Vaiva Cechanovičiūtė

thyroid cancer. FIRST step?

PALPATE thyroid

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thyroid cancer. first step - you do palpation. NEXT BEST step?

TSH

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thyroid cancer. Nodule + TSH normal/high (ie euthyroid or hypothyroid) –> what to do?

ULTRASOUND over FNA

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thyroid cancer. Nodule + TSH normal/high. UG vs FNA answer?

If both listed –> UG
If Ug not listed –> FNA

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thyroid cancer. Nodule + TSH low (ie hyperthyroid) –> ?

Radioiodine uptake scan (NOT UG)

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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

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TSH is screening for everyone except….

Pregnant

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What can be ordered after TSH?

T3 and T4, but usmle often omits this

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Screening for pregnancy?

Free-T4

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What is most diagnostic/accurate for everyone?

Free T4

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2CK hypothyroidism presentation. mood + treatment?

Low mood (dysthymia) –> mood improve with administration of thyroid hormone

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2CK hypothyroidism presentation. muscles + what lab?

proximal muscle weakness: difficulty getting up from chair unassisted +/- increased CK

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2CK hypothyroidism presentation. cholesterol?

Increased total cholesterol, eg 300mg/dl

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2CK hypothyroidism presentation. hepatic?

incr. AST

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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

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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

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If patient is not pscyh and suspect hypothyroidism, what investigation?

TSH is correct for hypothyroidism initial screening

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Hashimoto? Anti-microsomal (aka anti-thyroperoxidase) + anti-thyroglobulin antibodies.

T3 low, T4 low, TSH high
iodine uptake decreased or patchy

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Subclinical hypothyroidism?

normal T3, normal T4, TSH high
uptake normal/reduced

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Euthyroid sick syndrome?

decr T3, high reverse T3, normal T4, normal TSH

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Graves? antibody is called thyroid- stimulating immunoglobulin (TSI).

high T3, high T4, TSH low
uptake diffuse

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Toxic multinodular goiter?

high T3, high T4, TSH low
high multifocal/multinodular uptake

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Toxic adenoma?

high T3, high T4, TSH low
high uptake isolated to one nodule

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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.

Hashimoto assoc. with autoimmune diseases

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

Factitious: Q will give hyperthyroid patient with small, non-palpable thyroid gland (atrophic due to suppressed TSH).

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

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).

for deQuervain = Viral infections are often asymptomatic, so most deQuervain vignettes will not mention the viral infection.

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.