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Gen Med: Ednocrine > Thyroid > Flashcards

Thyroid Flashcards

1
Q

What is hyperthyroidism?

A

Hypermetabolic state resulting from excess thyroid hormone

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2
Q

What are the results of Hyperthyroidism?

A

↑ Metabolic rate
Excessive body heat generation
↑ Cardiac activity

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3
Q

What are the causes of hyperthyroidism?

A 
1. More common in Caucasian & Hispanic
populations
2. Females > males
3. Familial tendency
4. Autoimmune Dz 
5. Overexposure to iodine
A. Expectorants, amiodarone, seaweed, contrast dye
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4
Q

What is grave’s dz?

A
  1. Most common cause (80-90% of cases)
  2. Diffuse toxic goiter
  3. Autoimmune Dz
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5
Q

What is toxic adenoma?

A
  1. Single benign hyperfunctioning thyroid tumor resulting from a geneticmutation
  2. “Hot” thyroid nodule
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6
Q

What is Toxic Multinodular Goiter (Plummer’s Dz)?

A

2° to hyperplasticresponse of entire thyroid gland to a stimulus (iodine deficiency)

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7
Q

What is Transient Thyroiditis?

A
  1. Subacute thyroiditis
    A. Can causethyrotoxicosis&hypothyroidism
    B. De Quervain’s thyroiditis
    -Sudden, painful enlargement of thyroidgland w/fever,malaise& muscle aches (viral mediated)
  2. Hashimoto’s thyroiditis
    A. Autoimmune disease
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8
Q

What are the rare causes of hyperthyroidism?

A
  1. ↑ Iodine ingestion w/preexisting thyroid hyperplasia or adenoma
  2. Thyroid neoplasm
  3. Amiodarone
  4. Hydatidiform mole
  5. Pituitary neoplasm
    A. Hypersecretes TSH
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9
Q

What are the sxs of hyperthyroidism?

A 
Wt. loss 
↑ Appetite 
Diarrhea
Anxiety
Irritability
Heat intolerance
Palpitations
Tremor
Hyperactivity
↓ Menses (oligomenorrhea,  	  	                       amenorrhea)
Hyperreflexia
Diaphoresis
Hyperactivity
Tachycardia
Systolic HTN
Tremor
Warm, moist skin
Thin, fine hair 
Lid lag
Stare
Muscle weakness
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10
Q

What are the sxs of grave’s dz?

A
  1. Exophthalmos
  2. Lid retraction
  3. Lid lag
  4. Goiter
  5. Painless pretibial swelling (myxedema)
  6. Less common
    A. Diplopia
    B. Blurred vision
    C. Photphobia
    D. Increased lacrimatio
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11
Q

What is thyroid storm/severe thyrotoxicosis?

A
  1. Abrupt, severe exacerbation of thyrotoxicosis

2. Rare potentially fatal complication of hyperthyroidism

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12
Q

What causes thyroid storm/severe thyrotoxicosis?

A
  1. Occurs in patients with untreated (or undiagnosed) or undertreated hyperthyroidism
  2. Precipitating event
    A. Trauma
    B. Infection
    C. Surgery
    D. Parturition
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13
Q

What are the sxs of thyroid storm?

A
  1. High fever
  2. Tachycardia (>140)
  3. CHF in elderly
  4. N/V
  5. Tremor
  6. Mental status changes (psychosis, coma, seizures)
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14
Q

What are the dx studies for hyperthyroidism?

A
  1. ↓ TSH
  2. ↑ Free Thyroxine (Free T4)
    A. Normal in subclinical hyperthyroidism
    -Pituitary adenoma secreting TSH
  3. ↑ Free Triiodothyronine (Free T3)
  4. Anti-TPO Ab (anti-thyroid peroxidase Ab)
    A. ↑ in Graves’ Dz
  5. Anti-TSHR Ab (antithyrotropic receptor Ab)
    A. ↑ in Graves’ Dz
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15
Q

What imaging and further studies are used in hyperthroidism?

A
  1. Thyroid U/S
    A. If thyroid nodule or nodular goiter on exam
  2. 24-hr radioiodine uptake (I-123) & scan
    A. Urine or serum HCG prior to testing
  3. FNA & Bx if nodule confirmed
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16
Q

What are the I-123 Uptake and scan results in Toxic adenoma?

A
  1. Normal gland size
  2. “Hot” nodule
  3. Single focus of uptake
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17
Q

What are the I-123 Uptake and scan results in graves’ disease?

A
  1. Diffuse glandular enlargement

2. ↑ Homogenous I-123 uptake

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18
Q

What are the I-123 Uptake and scan results in a multinodular goiter?

A
  1. Diffuse enlargement w/ nodules

2. Areas of ↑ & ↓ I-123 uptake (heterogenous)

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19
Q

What disorders require a thyroid biopsy?

A

All “cold nodules” require biopsy to R/O thyroid cancer

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20
Q

How does radioactive Iodine treat hyperthyroidism?

A
  1. Destroys gland
  2. Most common treatment in non-pregnant adults, patients w/ large goiters, euthyroid not met after 1 yr of oral Tx, & when malignancy is likely (prior to surgery)
  3. Single oral dose
  4. Can worsen eye sx’s
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21
Q

What are examples and functions of the thionamide drugs?

A
  1. Methimazole/Tapazole (MMI) or Propylthiouracil (PTU)

A. Blocks production of thyroid peroxidase/inhibits new hormone synthesis

22
Q

What is the goal of hyperthyroid treatment?

A
  1. euthyroid in 3-8 wks and cont. for 12 to 24 mo.

2. Useful in preparing patients for surgery or radioactive iodine treatment

23
Q

What is the drug of choice for hyperthyroidism in pregnant and breast feeding women?

A

Propylthiouracil (PTU)

24
Q

What are the benefits of Methimazole/Tapazole (preferred) over PTU?

A

Lower S/E, longer duration of activity

Agranulocytosis - rare complication

25
Q

What is the role of steroidsin the treatment of hyperthyroidism?

A
  1. Inhibits peripheral T4->T3 conversion

2. Ophthalmopathy responds best to IV methylprednisolone, or high-dose tapered prednisone Tx

26
Q

Why are beta blockers used in hyperthyroidism?

A
  1. Propranolol controls palps, tachy, anxiety, tremors

2. Initial treatment of choice for Thyroid Storm

27
Q

What are the surgical options for hyperthyroidism?

A

Thyroidectomy- partial vs total

requires thyroid hormone supplementation

28
Q

What are the indications for thyroid surgery?

A
  1. Children (Graves’)
  2. Pregnant women
  3. Pts who refuse I-131 therapy
  4. Pts w/ severe eye symptoms
  5. Requires thyroid hormone supplementation
29
Q

What pt education needs to take place for hyperthyroidism?

A
  1. Refer pt to Ophthalmologist
    A. Emergency care for eye pain, optic nerve compression, color vision loss
  2. Smoking cessation-worsens eye symptoms
  3. Medication compliance is important
    A. Risk of thyroid storm
    B. Patient education on symptoms/risk
30
Q

How is thyroid storm treated?

A
  1. ICU
  2. Treat underlying cause (infection, etc)
  3. Tylenol
  4. Beta Blocker
  5. Tapazole/methimazole
    A. 80-100 mg PO or PR stat, then 30 mg PR q 8h
  6. Inhibit thyroid hormone release
    A. Lugol’s sol’n: Iodide 10 gtts q 8h OR Sodium iodide 250 mg IV q 6h
    B. Corticoteroids: Hydrocortisone 100 mg IV Q8h
31
Q

define hypothyroidism

A
  1. Inadequate secretion of thyroid hormone
  2. > 90% of cases are primary caused by thyroid gland dysfunction
  3. More common in caucasian females
  4. ↑ prevalence w/ age
32
Q

What are the causes of primary hypothyroidism?

A
  1. Autoimmune
    A. Hashimoto’s thyroiditis (most common cause > age 8)
    -Cell- & Ab-mediated destruction of thyroid tissue
    B. Previous thyroid surgery
    C. Radioactive iodine therapy
    D. External radiotherapy
    E. Meds such as lithium, amiodarone, sulfonamides, interferon, interleukin-2
    F. Congenital ≈ 1 per 4000 births
33
Q

What are the causes of secondary hypothyroidism?

A
  1. Pituitary dysfunction
  2. Postpartum necrosis
  3. Neoplasm
34
Q

What are the sxs of hypothyroidism?

A
  1. Thinning, dry hair
  2. Loss of outer 1/3 of brows
  3. Skin
    A. Dry, coarse, cool, edema of eyelids & hands (myxedema)
  4. Fatigue
  5. Wt. gain
  6. ↓ Appetite
  7. Poor memory
  8. Depression
  9. Cold intolerance
  10. Dulled expression
  11. Macroglossia: uncommon unless longstanding untreated hypothyroid
  12. +/- Thyromegaly
  13. Bradycardia
  14. Slow relaxation phase of DTR’s
  15. Possible CTS (carpal tunnel syndrome)
  16. Hyperlipidemia
  17. Anemia
  18. Hyponatremia
35
Q

What is the most common thyroid disorder in the US?

A
  1. Hashimoto’s Thyroiditis
  2. Affects 1% of the population & 5% over age 65
  3. More common in women 7:1
36
Q

What is the etiology and precipitating factors for hypothyroidism?

A
  1. Cause: combo of genetic & environmental factors
  2. Precipitating factors:
    A. Stress
    B. Pregnancy
    C. Excess iodine intake
    D. Radiation exposure
37
Q

What are the early signs of hashimoto’s thyroiditis?

A
  1. Tender enlarged thyroid
  2. Fever
  3. Tachycardia
  4. Diaphoresis
  5. Palpitations
  6. Wt. loss
38
Q

What are the late signs of hashimoto’s thyroiditis?

A
  1. +/- Nontender, enlarged thyroid
  2. Fatigue
  3. Wt. gain
  4. Delayed reflexes
39
Q

What are the characteristics of subclinical hypothyroidism?

A

TSH high, T4 normal

40
Q

What are the characteristics of secondary hypothyroidism?

A

Inadequate TSH secretion from pituitary

41
Q

What are the characteristics of tertiary hypothyroidism?

A

Inadequate thyrotropin-releasing hormone(TRH) from hypothalamus

42
Q

What is the ddx for hypothyroidism?

A
  1. Subclinical
  2. Chronic fatigue syndrome
  3. Secondary
  4. Tertiary
43
Q

What are the diagnostic studies in hypothyroidism?

A
  1. ↑ TSH
    A. Most sensitive screen (normal 0.50-5.0 mIU/L)
  2. ↓ Free T4
    A. Normal in subclinical hypothyroidism
  3. Thyroid autoantibodies (Anti-thyroid antibodies)
    A. Anti-TPO Ab (anti-thyroid peroxidase antibodies)
    B. Anti-Tg Ab (anti-thyroglobulin antibodies)
    C. ↑ in Hashimoto’s thyroiditis but not always
  4. Thyroid Scan
    A. Only for nodule
    B. Followed by FNA & Bx to R/O cancer
44
Q

How is hypothyroidism treated?

A
  1. Synthetic thyroxine (T4)
    A. Levothyroxine daily am dose
  2. Surgery
    A. Thyroidectomy if large gland compromises tracheoesophageal function or suspicious for malignancy
45
Q

What is myxedma coma?

A
  1. Severe hypothyroidism leading to ↓ mental status & hypothermia
  2. Medical Emergency w/ high mortality rate
46
Q

What causes myxedema coma?

A
  1. Long standing undiagnosed or undertreated hypothyroidism
  2. With additional insult
    A. Infection (pneumonia)
    B. Systemic disease
    C. Stroke/CHF/MI
    D. Medications: Sedatives, anesthetics, opiates, antidepressants)
    E. Cold exposure
    F. Trauma
    G. Surgery
    I. pregnancy
47
Q

What are the the sxs of myxedema coma?

A
  1. General: Hypothermia ( < 95° F rectal)
  2. HEENT: Myxedema facies, macroglossia
  3. Neuro: Lethargy or stupor, areflexia
  4. Cardiac: Hypotension/shock, bradycardia, low cardiac output
  5. Vascular: ↓plasma volume, increased vascular permeability, fluid accumulation
  6. Pulmonary: Depressed resp. drive, pleural effusions
  7. Renal/GU: Bladder distention, hyponatremia
  8. GI: Gastric atony, megacolon, ileus
48
Q

What is the treatment for myxedema coma?

A
  1. ICU
  2. Airway-if resp acidosis
  3. T4 loading dose
    A. Levothyroxine 300-500 mcg IV over 15 min, then 100 mcg IV q 24 h
  4. Hydrocortisone 100 mg IV bolus, then 50 mg IV q 12 h
    A. Give until adrenal insuff. is ruled out (normal serum cortisol)
  5. Progressive rewarming of pt
  6. Pan-culture then empiric Abx
  7. IV hydration w/ D5NS
  8. +/- Vasopressors
49
Q

What is the tx for hashimoto’s thyroiditis?

A
  1. Start thyroid hormone replacement Tx
    A. Prevents or corrects the hypothyroidism
    B. Halts thyromegaly
50
Q

What can hashimoto’s thyroiditis initially present as? How do you managed this?

A
  1. Can initially present as hyperthyroidism
  2. Treatment-until initial hyperthyroid period resolves
    A. Bed rest & NSAIDs
    B. Some need steroids to ↓ inflammation & control palpitations
    C. Beta blocker to ↓ the HR & ↓ tremors
51
Q

What are the indications to treat myxedema-suspected pts before labs come back?

A
  1. Thyroidectomy scar
  2. Hx of I131 therapy
  3. Hypothyroidism
52
Q

What are the dx studies for myxedema coma?

A
  1. ↑↑ TSH
  2. ↓ Free T4
  3. CBC w/diff, UC, BC x 2
  4. CXR
  5. CMP
  6. ABG’s
  7. Serum cortisol (R/O adrenal insuff.)
  8. ↑ CPK
  9. Hyperlipidemia

Gen Med: Ednocrine (8 decks)

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