Thyroid!

Question 1

Thyrotoxicosis

Answer 1

↑T4 - gland hyperfunction

Question 2

Thyrotoxicosis symptoms

Answer 2

Diarrhoea
Increased appetite/wt loss
Sweats, heat intolerance
Palpitations, AF 
Tremor
Manic/irritability/anxiety 
Oligomenorrhoea/infertility

Question 3

Thyrotoxicosis signs

Answer 3

Fast/irregular pulse
Fine tremor
Palmer erythema
Thin hair
Lid lag/retraction
Goitre 
Nodules

Question 4

Causes of thyrotoxicosis

Answer 4

Graves disease
Toxic multinodular goitre
Drugs (amiodarone)

Question 5

Thyrotoxicosis investigations

Answer 5

Low TSH
Increased T4 &T3
Increased calcium & LFTs

Question 6

What is Graves disease?

Answer 6

autoimmune over activation of thyroid
anti-TSH antibodies
T1DM, vitiligo, addisons

Question 7

Graves specific signs!

Answer 7

Diffuse goitre
Exophthalmos
Pre-tibial myxoedema (lesions)
Thyroid acropachy (clubbing/thick)

Question 8

Hyperthyroidism treatment

Answer 8

Propanolol - 4 symptoms like tremor
Carbimazole - blocks thyroid peroxidase/hormone synth
reduce gradually 
SE: agranulocytosis
If relapse - radioiodine treatment

Question 9

Thyroid treatment in pregnancy

Answer 9

hyper = propylthiouracil 
hypo = increase dose up to 50%

Question 10

Thyroid synthesis

Answer 10

Hypothalamus –> TRH - thyrotropin releasing hormone
Ant pit –> TSH - thyroid stimulating hormone
Thyroid:
T4 = Thyroxine
T3 = Triiodothyronine
regulate energy source use, protein synth, bodies sensitivity to other hormones

Question 11

Hypothyroidism types?

Answer 11

Primary - gland problem /autoimmune d
Secondary - pituitary disorder/compression
Congenital

Question 12

Hypothyroidism symptoms

Answer 12

Weight gain
Lethargy 
Cold intolerance
Dry anhidrosis, cold, yellow skin
Non-pitting oedema - hands, face
Dry, coarse scalp hair
Loss of lateral aspect of eyebrows
Constipation 
Menorrhagia
Decreased deep tendon reflexes
Carpal tunnel syndrome

Question 13

Hashimoto’s thyroiditis

Answer 13

Autoimmune hypothyroidism
TPO +ve
Goitre
can have transient thyrotoxicosis in acute phase

Question 14

De Quervains

Answer 14

Subacute thyroiditis
painful goitre
post viral URTI
raised ESR

Question 15

Causes of hypothyroidism

Answer 15

Hashimotos
De Quervains
Iodine deficiency 
Post partum 
Drugs - carbimazole, lithium, amiodarone
*Atrophic thyroiditis (UK)

Question 16

Atrophic Thyroiditis

Answer 16

anti-TPO, anti-TSH +ve
No goitre
Pernicious anaemia, vitiligo

Question 17

Hypothyroidism investigations?

Answer 17

high TSH
low T3/T4
increased MCV, normochromic anaemia 
increased triglyceride, cholesterol
hyponatraemia (SIADH)
TPO, TSH antibodies

Question 18

Hypothyroidism management?

Answer 18

Levothyroxine

Question 19

thyroid storm

Answer 19

acute, life-threatening
excessive thyroid hormones
treat: beta blockers, propylthiouracil and hydrocortisone

Question 20

myxoedema coma

Answer 20

severe hypothyroidism!
Hypothermia, hypoglycaemia
Heart failure: bradycardia, low bp, coma, seizures

Question 21

Simple goitre

Answer 21

Diffuse painless 
Dysphagia
Stridor
SVC obstruction
Usually euthyroid
Iodine deficiency

Question 22

Papillary thyroid malignancy

Answer 22

Follicular cells
Tg tumour marker
Lateral aberrant thyroid
Total thyroidectomy, node excision, radioiodine
T4 to suppress TSH

Question 23

Parathyroid hormone

Answer 23

Low Calcium => PTH secretion
- Increases osteoclast activity 
- Increases Ca2+ 
- Decreases PO4 resorption in kidney 
Kapow!
- Increases a-hydroxylation of 25OH-vitD3

Question 24

Primary hyperparathyroidism

Answer 24

Solitary adenoma
Hyperplasia of gland
Ca2+ increased inappropriately 
- normal PTH
- increased ALP
- decreased PO4

Question 25

Primary hyperparathyroidism investigation

Answer 25

ECG - decreased QTc, Brady cardia, 1st d HB
X ray - osteitis fibrosa cystica –> phalangeal erosions
DEXA - osteoporosis

Question 26

Parathyroid hormone

Answer 26

Low Calcium => PTH secretion
- Increases osteoclast activity 
- Increases Ca2+ 
- Decreases PO4 resorption in kidney 
Kapow!
- Increases a-hydroxylation of 25OH-vitD3

Question 27

Primary hyperparathyroidism

Answer 27

Solitary adenoma
Hyperplasia of gland
Ca2+ increased inappropriately 
- normal PTH
- increased ALP
- decreased PO4

Question 28

Primary hyperparathyroidism investigation

Answer 28

ECG - decreased QTc, Brady cardia, 1st d HB
X ray - osteitis fibrosa cystica –> phalangeal erosions
DEXA - osteoporosis

Question 29

Primary hyperparathyroidism mgmt?

Answer 29

Increase fluid intake
Avoid dietary Ca2+ and thiazides (increase serum Ca)
Surgical excision of adenoma

Question 30

Secondary hyperparathyroidism causes?

Answer 30

Vitamin D deficiency
Chronic renal failure
- bone disease, osteitis fibrosa cystica
- soft tissue calcifications

Question 31

Secondary hyperparathyroidism mgmt?

Answer 31

Phosphate binders 
- With Ca - calcichew
- Without - sevelamer, lanthanum 
Vitamin D
- calcitrol = active
- cholecalciferol = inactive

Question 32

Tertiary hyperparathyroidism causes

Answer 32

Prolonged secondary HPT –> autonomous PTH secretion

Question 33

Tertiary hyperparathyroidism

Answer 33

v high PTH, high Ca,

always w CKD

Question 34

Tertiary hyperparathyroidism mgmt?

Answer 34

if not resolved
remove affected gland or
total parathyroidectomy

Question 35

symptoms of low calcium? hypoHPT

Answer 35

Spasms - Trousseau’s sign
Perioral paraesthesia
Anxious, irritable
Seizures
Muscle tone increase - colic, wheeze, dysphagia
Orientation - confusion
Dermatitis
Impetigo herpetiformis 
Chovsteks, cardiomyopathy (↑ QTc → TdP)

Question 36

Causes of Hypoparathyroidism

Answer 36

Autoimmune

Congenital - DiGeorge

Question 37

Hypoparathyroidism mgmt?

Answer 37

Ca supplements

Calcitriol

Question 38

Hypoparathyroidism

Answer 38

Decreased PTH due to gland failure 
so low calcium!!!!
low Ca
high PO4 
lowPTH
normal ALP