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ENDO/ID FInal > Thyroid and Parathyroid > Flashcards

Thyroid and Parathyroid Flashcards

1
Q

function of thyroid gland

list hormones as well

A

Secretion of hormones

  • Thyroxine T4
  • Triiodothyronine T3
  • Reverse T3 (inactive form of T3)
  • Calcitonin

Both modulate metabolism

  • Energy utilization
  • Heat production

Regulate/facilitate growth

Brain development

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2
Q

biofeedback control of thyroid hormones

A
  1. Hypothalamus releases Thyroid Releasing Hormone (TRH) –> Stimulates pituitary to release TSH
  2. TSH then binds to the thyroid, which then secretes T4 and T3 –> inhibit secretion of TSH
    • directly and indirectly by suppressing the release of TRH
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3
Q

list common dz assoc w/ hyperthyroidism

A

Graves disease (autoimmune) 60% of cases

  • Autoantibodies bind to the TSH receptor –> stimulate the gland to ‘hyper function’ –> excess hormones

Toxic multinodular goiter

  • Focal or diffuse follicular hyperplasia
  • High level of nodularity

Toxic nodular goiter (Plummer’s disease)

  • Single hyperfunctional nodule
  • “Hot” on thyroid scan

Other

  • Pituitary adenoma (TSH secreting)
  • Meds (ex. amiodarone, lithium)
  • Head/neck radiation
  • Neck surgery
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4
Q

si/sx of hyperthyroidism

A
  • Periorbital edema
  • Diplopia, Proptosis , Exophthalmos
  • Tachycardia/arrhythmia (ex. palpitations)
  • Irritability/nervousness
  • Sweating/heat intolerance
  • DEC concentration/ Fatigue
  • Muscle weakness/cramps
  • Weight loss despite ­ appetite
  • Skin Δ (dermopathy) on lateral aspects of shins
  • Acropathy (nail clubbing)
  • +/- hyperreflexia
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5
Q

dx hyperthyroidism

Graves?

A

DEC TSH

­ INC T3 (total) /T4 (free)

+/- abs (Graves)

  • Anti-thyroid perixodase antibody (Anti-TPO)
  • Anti- Thyrotropin receptor antibodies 80-90%
  • Thyroid-stimulating immunoglobulin (TSI)
  • ­INC Ca
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6
Q

imaging hyperthyroidism

A

US +/- doppler – FIRST line (Cyst vs. solid)

Nuclear scintigraphy w/ RAIU (­ uptake)

  • Technetium (Tc-99) or Iodine (I-123)
  • info about size/shape of gland
  • Location of functional activity within the gland

Type of functioning

  • Warm/hot “functioning nodule”
  • Cold “non-functioning nodule” (malignancy)
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7
Q

tx graves dz

A

Thioamides (side of choice agranulocytosis)

  • Methimazole –> Requires tapering down to maintenance
  • Propythiouracil (PTU) –> pregnancy & Also requires tapering

Mild disease, small goiter –> Goal of remission after 1 year of treatment

  • Treat additional year if still (+) antibodies

Pre-op patients –> To get them Euthyroid

Radioactive iodine – Tx of choice

Surgery (subtotal vs. total)

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8
Q

Tx of Toxic multinodular goiter

A

Sub-total thyroidectomy > Radioactive Iodine (131 Iodine)

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9
Q

tx of Toxic nodular goiter (Plummer’s disease)

A

Radioactive Iodine (131 Iodine) > unilateral lobectomy

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10
Q

Toxic multinodular goiter

VS

Toxic nodular goiter (Plummer’s disease)

A

Toxic multinodular goiter - High level of nodularity

  • Focal or diffuse follicular hyperplasia

Toxic nodular goiter (Plummer’s disease)

  • Single hyperfunctional nodule
  • “Hot” on thyroid scan
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11
Q

on Nuclear scintigraphy w/ RAIU (­ INC uptake) is a warm or cold nodule assoc w/ malignancy

A

Warm/hot “functioning nodule”

Cold “non-functioning nodule” (malignancy)

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12
Q

define thyroid storm

A

Untreated hyperthyroidism - SEVERE

•Can be brought on by stress (ex. trauma, MI, infection)

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13
Q

si/sx of thyroid storm

A

Exaggerated presentation of hyperthyroidism

  • Tachycardiac (>140 bpm)
  • HTN à CHF
  • Fever (104-106°)
  • AMS - Agitation, delirium, psychosis, stupor, or coma
  • N/V / Abdominal pain
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14
Q

tx thyroid storm

A

Beta-blocker – control HR

IV thionamide - to block new hormone synthesis

PO Lugol’s solution - to block the release of thyroid hormone

Iodinated radiocontrast- to inhibit the peripheral conversion of T4- to-T3

Hydrocortisone - ↓T4-to-T3 conversion

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15
Q

define thyrotoxicosis & most commonc cause of it

define subacute thyroititis & common cause

A
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16
Q

thyroid scan - diffuse uptake or irregular/diminished upstake

Graves

Toxic multinod

Toxic goiter - plummers dz

A

diffuse uptake - Graves

irregular/diminished upstake

  • Toxic multinod
  • Toxic goiter - plummers dz
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17
Q

list types of Hypothyroidism

A

Hashimoto’s (autoimmune thyroiditis)

  • B-lymphocytes invade thyroid and produce autoabs
  • Hashimoto’s is #1 cause in US
  • Iodine Deficiency #1 cause in developing countries
  • Most common inflammatory condition of thyroid gland
  • Most common cause of goiter
  • ‘Body attacks thyroid’, destroys thyroidà B-lymphocytes invade the thyroid gland –> “chronic lymphocytic thyroiditis”

Other:

  • Iodine deficiency
  • Thyroidectomy
  • Deficient HPO axis - Central hypothyroidism
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18
Q

Most common inflammatory condition of thyroid gland

Most common cause of goiter

developing countries?

A

hashimotos hypothyroidism

Iodine Deficiency #1 cause in developing countries

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19
Q

si/sx of hypothyroidism

A
  • Fatigue/lethargy
  • Cold intolerance
  • Constipation
  • Weight gain / Depression
  • Menorrhagia
  • Hoarseness
  • Weakness/ Myalgias/arthralgias
  • HA
  • Dry skin
  • Coarse, thinning hair
  • Periorbital edema
  • Bradycardia
  • Hyporeflexia - ↓DTRS

Gland is diffusely enlarged; firm and rubbery and nodular –> atrophic and fibrotic

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20
Q

dx hypothyroid

A

INC­ TSH

DEC T3/T4

+/- abs (Hashimoto’s)

  • (+) autoantibodies (hallmark)
  • High titers of abs to thyroglobulin, thyroid peroxidase
  • ↑Anti-Thyroid Peroxidase (TPOAb)
  • ↑Thyroglobulin antibody (TgAb)
  • Thyroid Stimulating Blocking Antibodies (TSbAb)

Imaging:

  • US +/- doppler
  • Nuclear scintigraphy w/ RAIU –> (DEC uptake)
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21
Q

tx hypothyroidism

A

Levothyroxine (Synthroid) synthetic T4

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22
Q

Hyperthyroidism - ___TSH & ___ T3/T4

Hypothyroidism - ___TSH & ___ T3/T4

A

Hyperthyroidism - DEC TSH & INC T3/T4

Hypothyroidism - INC TSH & DEC T3/T4

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23
Q

define Myxedema coma

A

complciation opf hypothyroidism

Medication cessation

  • Impaired cognition, confusion à coma (myxedema coma)
  • Most often seen in elderly and those who have stopped taking meds
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24
Q

si/sx of Myxedema coma

A
  • AMS
  • Severe hypothermia
  • Hypoventilation
  • Hyponatremia
  • Hypoglycemia
  • Hypotension
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25
Q

Tx Myxedema coma

A

IV Levothyroxine – LARGE DOSES

Treat hypothermia – slowly warm to prevent cardiac events

+/- intubation/ mechanical ventilation

Monitor for infection

+/- hydrocortisone - Suspected concomitant adrenal insufficiency

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25
Q

Complication of hyperthyroid ___

Complication of hypothyroid ___

A

Complication of hyperthyroid: Thyroid storm

Complication of hypothyroid: Myxedema coma

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26
Q

2 classifications of Thyroiditis

A

Painful- Subacute granulomatous thyroiditis

Painless

  • Med induced (ex. amiodarone, lithium)
  • Hashimoto’s
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27
Q

list typea of thyroid nodules

A

Mostly Benign

  • Cyst
  • Follicular adenoma
  • Colloid nodule
  • Malignancy
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28
Q

malignnancy suspicition w/ thyroid nodule if..?

A
  • History of head/neck radiation
  • Young age
  • Recent onset, rapid growth
  • Family h/o medullary thyroid cancer
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29
Q

dx thyroid nodule

A

RAIU scan (hot vs. cold)

  • The hotter the nodule on scan, the less likely lesion/nodule is cancerous

Tissue Bx

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30
Q

List types of thyroid cancer

A

Papillary 60%

Follicular 20%

Anaplastic 14%

Medullary 5%

31
Q

si/sx of Thyroid cancer

A

•Painless, palpable, firm/fixed nodule

•Rapid growth

  • Vocal cord paralysis
  • Hoarseness
32
Q

thyroid cancer dx of choice

A

US guided fine needle aspiration

33
Q

type of thyroid cancer Linked to iodine deficiency

A

Follicular 20%

34
Q

thyroid cancer w/

↑ serum calcitonin levels confirm diagnosis

A

Medullary 5%

35
Q

tx of choice for what type of thyroid cancer:

Surgical isthmusectomy to Prevent tracheal compression

A

Anaplastic 14%

36
Q

tx of thyroid cancers

Papillary 60%

Follicular 20%

A

Lobectomy on lesions < 1.5 cm

1.5 cm lesions = near-total thyroidectomy

Life-long levothyroxine after surgery

37
Q

thyroid cancer seen in those >50 y/o

A

Anaplastic 14%

38
Q

thyroid cancer seen families (AD)

A

Medullary 5%

39
Q

dx thyroid cancer: reasons to use

US guided fine needle aspiration –

RAIU thyroid scan -

+/- CT/MRI w/o contrast -

A

US guided fine needle aspiration – dx of choice

RAIU thyroid scan - Can provide hint whether malignant or not

+/- CT/MRI w/o contrast - Evaluate soft tissue extension of large or suspicious thyroid mass

40
Q

tx of thyroid cancer

A

Surgery (subtotal vs. total)

  • Near-total’ vs lobectomy
  • Depends on lesion size and type
  • Modified neck dissection if evidence of lymph node metastases

Medication

Post-op triiodothyronine (T3) x 3 months

  • Stop T3, 2 weeks later

Thyroid Scan with radioactive Iodine-131

  • uptake…tx w/ radioactive Iodine-131
  • no uptake…levothyroxine to suppress TSH

Annual f/u

41
Q

tx thyroid cancer:

Thyroid Scan with radioactive Iodine-131

  • uptake…tx w/ _____
  • no uptake…______to suppress____
A

Thyroid Scan with radioactive Iodine-131

  • uptake…tx w/ radioactive Iodine-131
  • no uptake…levothyroxine to suppress TSH
42
Q

PTH monitors & regulates blood Ca++

Low Ca++ …?

High Ca++….?

A

Low Ca++ –> Parathyroid glands secrete PTH –> ↑Ca++

High Ca++ –> Thyroid gland release calcitonin –> ↓Ca++

43
Q

when do you need to correct serum Ca++

A

When hypo or hyperalbuminemia

Hypoalbuminemia can cause pseudohypocalcemia

Ca++ = Ca++ measured + (0.8 (4- measured albumin))

44
Q

PTH monitors & regulate PO4 levels

Low PO4

High PO4

A

Low PO4 –> Parathyroid glands secrete PTH –> ↑PO4

High PO4--> Parathyroid glands secrete PTH –> ↓PO4

45
Q

2 causes of Hypocalcemia (Ca+ < 8.5)

more common cause?

A

↓ calcium entering the blood- Most common cause

  • Vitamin D deficiency- may be ingesting Ca but unable to absorb from GI tract
  • Hypoparathyroidism/Pseudohypoparathyroidism

Too much calcium leaving the blood

  • Kidney failure- cannot reabsorb Ca++
  • 2o Hyperparathryoidism
  • Tissue injury & Inflammatory process
  • Acute pancreatitis- Free fatty acids bind to free Ca++
  • Too many blood transfusions- Additives bind to free Ca++
  • Hyperphosphatemia- Ca++ going to bone and extra-skeletal tissue
46
Q

pathophys of hypocalc

A

PTH stimulates bone resorption –> release Ca++ from bones into blood

PTH ↑ reabsorption of Ca++ in the kidneys

PTH activates 1, 25-(OH)2 VitD (active form) from 25-(OH) VitD (storage form from diet/sunlight)

Active Vitamin D (1,25-(OH)2 Vit D= calcitriol)

  • Active Vit D –> ↑intestinal Ca++ absorption
47
Q

si/sx of hypocalc

A

Chvostek sign & Trousseaus sign

Hyperreflexia

Tetany

Muscle spasms

Seizures

Abd pain

Prolonged QTc

48
Q

dx hypocalcemia

A

Chvostek sign & Trousseaus sign

ECG (prolonged QTc)

DEC Ca

Albumin (corrected Ca)

Dec PTH, Mg, 25-OH Vit D

INC PO4

49
Q

etiology of hypocalcemia

  • (INC/DEC ) PTH- Hypoparathroidism
  • (INC/DEC ) PTH- Kidney disease, Vit D deficiency, pseudohypoparathyroidism
A

↓PTH- Hypoparathroidism

↑PTH- Kidney disease, Vit D deficiency, pseudohypoparathyroidism

50
Q

tx hypocalcemia

A

Severe (<7.5), symptomatic

  • Supp. Mg FIRST
  • IV Ca+ gluconate
  • Admit to telemetry

Mild (>7.5), asymptomatic

  • PO Ca+ replacement
  • Vit D repletion
51
Q

most common cause of Hypoparathyroidism

A

↓PTH (cannot make PTH)

  • Surgery (thyroid or parathyroid-ectomy,
  • head/neck ca.)
  • Neck radiation
  • Autoimmune
  • Genetics
52
Q

si/sx of Hypoparathyroidism

acute

mild-mod

severe

A

Acute – Tetany (hallmark) - neuromuscular irritability

Mild-Mod

  • Asymptomatic
  • Perioral numbness, paresthesias of the hands and feet
  • Irritability, lethargy, anxiety
  • Muscle cramps/spasms

Severe

  • Carpopedal spasm (ex. Trouseau’s sign)
  • Laryngospasm
  • Refractory heart failure
  • Seizures
53
Q

dx Hypoparathyroidism

A

↓Ca++ ((PTH causes this to inc normally)

Cr / Albumin

↓PTH

Mg

25-(OH) Vit D

↑PO4 (PTH causes this to dec normally)

ECG –> QTc prolongation

54
Q

tx Hypoparathyroidism

severe

mild-mod

A

Severe

  • IV Ca++
  • IV Calcitriol (1,25-(OH)2 VitD – active form)

Mild- Moderate

  • PO Ca++
  • IV Calcitriol (1,25-(OH)2 VitD – active form)
55
Q

define Pseudo - hypoparathyroidism

A

Condition associated with resistance to PTH

56
Q

dx Pseudo - hypoparathyroidism

A

↓Ca++

↑PO4

↑PTH (appropriately high due to low Ca++)

57
Q

common causes of Hypercalcemia (Ca+ > 10.5)

A

Too much calcium entering the blood

  • Excessive bone resorption
  • Hyperparathyroidism
  • Malignant Tumors
  • Thyrotoxicosis
  • Paget Disease, others

Excessive calcium absorption

  • Excess Vit D
  • Milk alkali syndrome
  • Medications (thiazide dueretics)

Less calcium leaving the blood

  • Adrenal insufficiency
  • Adrenal failure
58
Q

si/sx of hypecalc

A

“Bones, Stones, Groans, & Psychiatric Moans”

  • Bone pain, Muscle weakness
  • Nephrolithiasis
  • Polyuria
  • Fatigue/lethargy
  • Confusion, hallucinations
  • Anxiety/ depression
  • Constipation, Nausea
  • Slow / absent reflexes

Calcitonin

  • Secreted from Thyroid gland
  • Opposes PTH –> ↓Ca++ in blood
59
Q

dx hypercalc

A
  • ECG (shorted QTc)
  • 24-hour urine
  • INC Ca
  • Albumin (↑corrected Ca)
  • ↓PTH- Malignancy, VitD intoxication
  • ↑PTH- 1o hyperparathyroidism, familial hypocalciuric hypercalcemia, 3o hyperparathyroidism
  • DEC Mg
  • INC 25-OH Vit D
60
Q

tx hypercalc

mild

mod-severe

A

Mild, asymptomatic

  • Treat underlying etiology
  • Oral fluids & PO4 repletion

Mod-severe (>14), symptomatic

  • IV fluids
  • Loop diuretics
  • Calcitonin
  • Bisphosphonates
  • Denosumab
  • Prednisone
61
Q

complciations

hypocalc

hypercalc

A

hypocalc - cardiac arrythmias (Torsades, afib)

hypercalc - cardiac arrythmias (bradycardia, AV block)

62
Q

names types of Hyperparathyroidism

A

Primary - Parathyroid gland secretes ↑PTH regardless of Ca++ leve

  • Parathyroid adenoma
  • Hyperplasia
  • Carcinoma
  • FHH

Secondary - Parathyroid gland hyperplasia

  • Prolonged CKD
  • Vit D deficiency

Tertiary - 2/2 2o Hyperparathyroidism after many years, Parathyroid gland secretes ↑PTH regardless of Ca++ level even if original cause corrected

  • ESRD
63
Q

Hyperparathyroidism Dx: Ca PO4 PTH

Primary

Secondary

Tertiary

A

Primary - ALL INC PTH

  • INC Ca
  • DEC PO4
  • INC PTH

Secondary - ONLY one to DEC Ca - (Ca and PO4 Oppisites)

  • DEC Ca
  • INC PO4
  • INC PTH

Tertiary

  • INC Ca
  • INC PTH
64
Q

dx imaging of Hyperparathyroidism

A

DXA scan- BMD

Skull Xray- “salt and pepper” –> Cystic bone spaces

Renal imaging to evaluate for stones –> XRay, CT, MRI

Sestamibi pararthyroid scan –>Indicated if doing surgery

65
Q

Tx Hyperparathyroidism

asymp

symp

acyte hypercalcemia

A

Asymptomatic : Observation +/- surgery

Symptomatic

  • Parathyroidectomy
  • Cinacalcet

Acute hypercalcemia

  • IV Fluids
  • Loop Diuretics
66
Q

complications of Hyperparathyroidism

A

Parathyroid adenoma

  • Profound hypocalcemia (Hungry Bone Syndrome)

Parathyroid carcinoma: Mets to bone & lung

67
Q

2 associations of Parathyroid Adenoma

A

Associated with MEN I (parathyroid, pancreatic tumor, pituitary adenoma)

Associated with MEN IIa (medullary carcinoma of the thyroid, pheochromocytoma, hyperplasia of the parathyroid)

68
Q

Parathyroid Adenoma most common location

A

Right inferior gland most common location–> Hyperactivity of one gland –> atrophy of remaining 3

69
Q

Parathyroid Adenoma si/sx

A

Si/sx of hypercalcemia

“Bones, Stones, Groans, & Psychiatric Moans”

  • Bone pain, Muscle weakness
  • Nephrolithiasis
  • Polyuria
  • Fatigue/lethargy
  • Confusion, hallucinations
  • Anxiety/ Depression
  • Constipation, Nausea
  • Slow / absent reflexes
70
Q

dx Parathyroid Adenoma

A

↑Ca++

↓PO4

↑PTH

Sestamibi scan – localizes the mass

71
Q

complication of Parathyroid Adenoma

A

Hungry Bone Syndrome after excision

  • Remove adenoma –> Remove excess PTH
  • Rapid, profound, prolonged hypocalcemia (calcium taken up by bone
72
Q

si/sx of Parathyroid Carcinoma

A

Symptoms of hypercalcemia

  • More likely to have sx vs a parathyroid adenoma, more likely to have neck mass

“Bones, Stones, Groans, & Psychiatric Moans”

  • Bone pain, Muscle weakness
  • Nephrolithiasis
  • Polyuria
  • Fatigue/lethargy
  • Confusion, hallucinations
  • Anxiety/ Depression
  • Constipation, Nausea
  • Slow / absent reflexes
73
Q

dx Parathyroid Carcinoma

A

↑Ca++

↓PO4

↑PTH (more likely to be abnormal vs parathyroid adenoma)

74
Q

complication of Parathyroid Carcinoma

A

Can metastasize to bone and lung

75
Q

Hypercalc - Hypo/er reflexia

hypocalc - Hypo/er rreflexia

A

Hypercalc - hyporeflexia

hypocalc - Hyperreflexia

76
Q

hypercal ECG -

hypocal ECG -

A

hypercal ECG - shorted QTc

hypocal ECG - prolonged QTc

ENDO/ID FInal (4 decks)

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