Thyroid

Question 1

Risk Factors for hyperthyroidism

Answer 1

Family history.
History of ordering disorders.
History of type one diabetes.
Diffuse not going to
Medication, such as iodine, lithium, amiodarone

Question 2

Aetiology of hyperthyroidism

Answer 2

Graves’ disease most common.
Toxic multicar goiter.
Toxic adenoma
Thyroiditis
Treatment induced.
Thyroid, tumor, or ovarian tumour that produces thyroid hormone

Question 3

Types of thyroiditis

Answer 3

Subacute thyroiditis usually resolves in eight months. Usually caused by infections.
Lymphocytic, thyroiditis or postpartum thyroiditis.

Question 4

Investigations for hyperthyroidism

Answer 4

Nose screening less patient high risk.
TSH, free, T4.
Low, TSH, high, T4, then radio iodine and uptake.
If high, TSH, high, T4, then MRI of the brain to rule out pituitary adenoma.
Consider cardiac evaluation such as ECG, echo, Holter, myocardial, perfusion studies
Baseline,. Hemoglobin, WBC, ALT, AST, bilirubin.

Question 5

Hyperthyroidism investigation algorithm

Answer 5

Elevated DSH elevated T4: secondary hyperthyroidism. MRI of the pituitary.
Low TSH elevated T4: radio iodine uptake.
Radio iodine, uptake, low: thyroiditis, exogenous, thyroid hormone, ectopic, thyroid hormone.
Radio ID update high: diffuse them, graves or Hashimoto. nodular uptake then, multinodular or toxic adenoma based on picture. FNAC, if nodular, but no update.

Question 6

Treatment of primary hyperthyroidism

Answer 6

Beta blocker
Methimazole or PTU
Radioactive iodine.
Sub total thyroid ectomy

Question 7

Treatment of sub clinical hyperthyroidism

Answer 7

Treatment not needed unless TSH less than zero point one or the patient is elderly, postmenopausal not on HRT, has osteoporosis or coronary artery disease

Question 8

Treatment of hyper thyroidism in pregnancy

Answer 8

Treatment of choice is subtotal thyroid ectomy in the second trimester
PTU is preferred over methimazole during pregnancy and breast-feeding.
Methimazole is contraindicated  in the first trimester

Question 9

Symptoms and treatment of thyroid storm

Answer 9

Symptoms of thyroid storm include fever, Cardia, CNS agitation, G.I. disturbance, CHF.
Fever is the cardinal symptom.
Bloodwork will show increased WBC, increased glucose, increased calcium, increased LFTs, increased three T4, decreased, TSH, decreased hemoglobin.
Treat withbeta blocker, methimazole, potassium, iodide, and glucocorticoids, along with fluids, oxygen cooling

Question 10

Aetiology of primary hypothyroidism

Answer 10

Chronic auto immune thyroiditis.
Postpartum thyroiditis.
Thyroid agenesis or dysgenesis
Subacute granulomatous thyroiditis
Thyroid surgery, radiation, radioiodine treatment.
Thyroid infiltration with cancer or sarcoidosis

Question 11

Causes of secondary or central hypothyroidism

Answer 11

Pituitary adenoma.
Pituitary damage with tumor, metastasis haemorrhage and necrosis and aneurism or surgery or trauma.
Pituitary infiltration with sarcoidosis tuberculosis

Question 12

Risk Factors for hypothyroidism

Answer 12

Pregnant vivid in the first trimester
postpartum the first six weeks to six months
Age 45 to 50+
We’ve been trying to conceive next nine in history of the disease in the family or immune disorder in the family next nine history of personal auto immune disease.
Prior neck radiation
Medication such as a lithium or iodine

Question 13

Investigations for hypothyroidism

Answer 13

TSH
T4
T3 only if undetectable TSH and normal free T4 and high suspicion of hypothyroidism.
Thyroid peroxidase antibodies plus thyroglobulin plus thyroid receptor antibodies.
Hemoglobin macrocytic anemia may be present.
Lipids.
If goitrePresent: radioiodine, uptake, or thyroid, scan, or MRI/ct of the thyroid
Ultrasound of the thyroid only if palpable abnormality of the thyroid gland

Question 14

What is the management of hypothyroidism?

Answer 14

Levothyroxine titrate every 4 to 6 weeks until TSH in target. And then every year after.
Take levothyroxine at least 30 minutes before breakfast or walk two hours after dinner
Avoid taking with caffeine, alcohol, other medication, as that may impair absorption

Question 15

At what time is treatment for hypothyroid warranted?

Answer 15

If TSH greater than 10, and patient is symptomatic
TSH between 5 to 10 and either presence of thyroid peroxidase antibodies or patient is pregnant or has strong family history of autoimmune disease or has a goitre

Question 16

If patient has viral infection, followed by painful enlarged thyroid, as well as symptoms of hypothyroidism. What is the diagnosis and what treatment should be given

Answer 16

Most likely acute granulomatous thyroiditis. Treatment would be NSAID. Usually self resolving

Question 17

management of hypothyroidism, diagnosed pregnancy

Answer 17

Stabilized TSHASAP.
Monitor every 2 to 3 weeks as compared to 4 to 6 weeks.
Take prenatal vitamins at different time than thyroxin
Will lead to decrease dose of levothyroxine postpartum

Question 18

Management of hypothyroidism, diagnosed prior to pregnancy

Answer 18

TSH less than 2.5 prior to conception
Check TSH as soon as pregnancy is confirmed.
May need to increase thyroxin dose by 30 to 40% in the first 4 to 6 weeks.
Monitor regularly during pregnancy

Question 19

When should the patient with hypothyroidism be referred?

Answer 19

Refer if patient has.
Central hypothyroidism.
Myxedema,
CAD.
Arrhythmia

Question 20

Risk factors for malignancy, in a thyroid nodule

Answer 20

Rapid growth of nodule with the presence of dysphasia, dyspnea, dysphonia, personal history of MEN, FAP, history of neck, radiation, family, history of thyroid cancer

Question 21

Physical findings in a thyroid nodule, indicative of malignancy

Answer 21

Size greater than 4 cm
Irregular, farm.
Fixed.
Associated lymphadenopathy.
Vocal cord palsy

Question 22

Investigation of thyroid nodule on exam

Answer 22

T4.
Thyroid ultrasound.
Radio iodine uptake
FNAC if greater than 1 cm or less than 1 cm and concerning findings on ultrasound If AFLAC non diagnostic. Repeat in one to four weeks. Benign follow up in six months. If concerning refer for surgery.

Question 23

Ultrasound, findings of thyroid nodule that are concerning for malignancy

Answer 23

Nodule that is taller than white
Presence of microcalcifications
Presence of calcified rim
Irregular border
Extending beyond the thyroid.
Lymph node involvement

Question 24

Symptoms and management of myxedema coma

Answer 24

It is an emergency.
Patient will be drowsy, confused, comatose, will have bradycardia, hypertension, bradypnea, hypothermia, decrease reflexes.
Treat with levothyroxine, liothyronine, glucocorticoid, IV fluids, oxygen, other supportive measures as needed