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Foundations III- Endocrine > thyroid and parathyroid > Flashcards

thyroid and parathyroid Flashcards

1
Q

what is the function of the thyroid gland?

A

secrete thyroid hormone

secrete calcitonin

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2
Q

Thyroglobulin

A

Protein that synthesizes and stores T3 and T4

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3
Q

Thyroid hormones

A

T3 (3,5,3’-triiodothyronine)

T4 (thyroxine)*

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4
Q

Hyperthalamus

A

releases TRH > TSH > T3/T4 to liver

…and

circulatory system –> which inhibits anterior pituitary gland and hypothalamus

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5
Q

2 causes of hypothyroidism

A

Generalized metabolic slowing

accumulation of matrix substances

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6
Q

S/s of Generalized metabolic slowing of hypothyroidism

A 
Fatigue, weakness
Cold intolerance
Weight gain
Cognitive dysfunction
Constipation
Slow movement/speech
Delayed relaxation DTRs
Bradycardia
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7
Q

s/s of accumulation of matrix substances of hypothyroidism

A 
Dry skin
Hoarseness
Edema
Coarse skin
Puffy facies
Loss of eyebrows
Periorbital edema
Tongue enlargement
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8
Q

other s/s of hypothyroidism

A 
Decreased hearing
Myalgias/arthralgias/paresthesias
Depression
Menstrual changes
Pubertal delay
Diastolic HTN
Pleural and pericardial effusions
Ascites
Galactorrhea
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9
Q

PE for pt suspected of hypothyroidism includes:

A 
Vitals 
Skin
HEENT
Neck
Cardiac
Respiratory
Abdominal
GU
Neuro
Extremity
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10
Q

PE exam findings for hypothyroidism

A

Vitals - bradycardia, HTN
respiratory - dec CO, dyspnea

skin - dry, hair loss, brittle nails, vitiligo, alopecia

abd- ascites, hypoactive bowel sounds, constipation

extremity- edema, carpal tunnel syndrome d/t edema

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11
Q

Labs for hypothyroidism

A

TSH (if only for screening):

**Free T4 (most important)

T3

other: BMP (Na & Cr), lipids (elevated), drug levels

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12
Q

what will TSH look like in hypothyroidism?

A

TSH will be high

upper limit of normal, usu. 4-5mU/L

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13
Q

what will T4 and TSH look like in primary hypothyroidism?

A 
T4 = low
TSH = high
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14
Q

what will T4 and TSH look like in subclinical hypothyroidism?

A 
T4 = normal
TSH = high
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15
Q

Anti TPO antibody expected result…

A

Elevated in Hashimoto’s thyroiditis

Elevated in Grave’s disease

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16
Q

Anti thyroglobulin antibody expected result…

A

Elevated in Hashimoto’s thyroiditis

Elevated in Grave’s disease

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17
Q

Thyroid Stimulating Immunoglobulin (TSH Receptor Antibody) expected result…

A

Grave’s disease (65%)

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18
Q

when are you NOT concerned if pt has anti-thyroid antibodies?

A

if pt is asymptomatic

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19
Q

hypothyroidism etiology?

A 
Autoimmune thyroiditis (Hashimoto’s)
Iatrogenic (radiation, sx)
Iodine deficiency or excess
Meds
Transient
Infiltrative (rare)
Congenital
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20
Q

which pt’s are at increased risk for hypothyroidism?

A 
Goiter
History of autoimmune dz
Previous radioactive iodine therapy
Hx head/neck irradiation
Family hx thyroid disease
Meds that impair thyroid fx

also, pt’s with lab or radiologic abnormalities that could be caused by hypothyroidism

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21
Q

which meds are known to impair thyroid function?

A

Lithium, amiodorone, aminoglutethimide, interferon α, thalidomide, betaroxine, stavudine

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22
Q

what is the main tx & management for hypothyroidism?

A

Synthetic thyroxine (T4) replacement

to achieve and maintain euthyroid state

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23
Q

what meds are used to tx hypothyroidism? and why is it a good functional med?

A

Levothroid, Levoxyl, Synthroid

High absorption, long half life

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24
Q

what is the average dose for Levothroid, Levoxyl, Synthroid?

in elderly?

hx Coronary hx dz?

A

dose avg. 1.6mcg/kg/day

elderly - 25-50mc/kg/day

hx Coronary heart dz - 25mc/kg/day

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25
Q

goals of tx for hypothyroidism?

A

Symptom relief
Normalization of TSH secretion
If applicable, decrease in goiter size

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26
Q

how often should you monitor pt when administering new medications?

A

q 6weeks

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27
Q

what are other tx options available for hypothyroidism? why are they not 1st line?

A

T3 (Cytomel)/T4 combo therapy (bad bc highly variable w/short half life)

Dessicated thyroid extract (Armour Thyroid, Nature Throid) (absorption/metabolized variable)

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28
Q

how many pt’s w/subclinical hypothyroidism progress to overt hypothyroidism?

A

1/3 to 1/2

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29
Q

possible assoc. with subclinical hypothyroidism?

A

CV disease
NAFLD
Neuropsychiatric
Reproductive

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30
Q

tx for subclinical hypothyroidism?

A

TSH > 10 –> supplement w/thyroid hormone

TSH ULN - 10 –> clinical presentation??

(but free T4 normal)

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31
Q

etiology of hyperthyroidism?

A

MC = Autoimmune thyroid disease

Autonomous thyroid tissue

TSH-mediated
hyperthyroidism

Human chorionic gonadotropin-mediated hyperthyroidism

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32
Q

what dz’s are considered Autoimmune thyroid diseases?

A

Graves’ disease

Hashimoto’s thyroiditis

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33
Q

what dz’s are considered autonomous thyroid tissue?

A

Toxic adenoma

Toxic multinodular goiter

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34
Q

what dz’s are considered TSH-mediated hyperthyroidism?

A

TSH-producing pituitary adenoma (rare)

Non-neoplastic TSH-mediated hyperthyroidism

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35
Q

clinical presentation for hyperthyroidism?

A 
Skin changes
Stare and lid lag
**Graves’ ophthalmopathy (specific finding)
Cardiovascular (tachy, Afib)
Low total and HDL cholesterol
Impaired glucose tolerance
Dyspnea and DOE
Weight loss
Normochromic, normocytic anemia
Genitourinary
Bone changes
Neuropsychiatric change
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36
Q

labs for hyperthyroidism?

A

TSH (low), T3 & T4 (high)

other: *TSH receptor antibody
&
antithyroglobulin antibody, antithyroperoxidase antibodies, ANA, anti-dsDNA antibodies

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37
Q

diagnostic tools for hyperthyroidism?

A

24 hour radioiodine uptake and scan

38
Q

Contraindications for 24 hour radioiodine uptake and scan

A

pregnancy & breastfeeding

39
Q

what does high uptake and low uptake indicate on 24 hour radioiodine uptake and scan?

A

High uptake = increased hormone synthesis

Low uptake = inflammation/destruction of thyroid gland or extrathyroidal source of thyroid hormone

40
Q

Tx options for hyperthyroidism?

A 
Beta-blockers
Thionamides (Methimazole
Propylthiouracil (PTU))
Radioiodine ablation
Surgery
41
Q

subacute thyroiditis aka…

A

granulomatous, de Quervain’s, giant cell thyroiditis

42
Q

clinical presentation for subacute thyroiditis?

A

p/w acute symptoms or silently
Common in young/middle-aged females
assoc. w/viral illness

acutely painful glandular enlargement with dysphagia

43
Q

who is subacute thyroiditis dx’d

A

clinical w/labs

44
Q

how is subacute thyroiditis tx’d?

A

with anti-inflammatories (ASA, NSAIDS, prednisone) and symptom management

45
Q

etiology of thyroiditis?

A
  1. thyroiditis:
    subacute granulomatous (de Quervain’s) thyroiditis,
    painless thyroiditis, postpartum thyroiditis, amiodarone-induced, radiation thyroiditis, palpation thyroiditis
  2. Exogenous thyroid hormone intake: excessive replacement therapy, intentional suppressive therapy
46
Q

during 1st trimester pregnancy, what is the preferred med in pregnancy?

A

propylthiouracil

47
Q

what is a thyroid storm?

A

Rare, acute endocrine emergency

w/ high mortality usu. results from an acute event

48
Q

risk factors for thyroid storm?

A 
Surgery
Trauma
Infection
Iodine adminsitration
Childbirth
Withdrawal of antithyroid meds
MI, CVA, PE
49
Q

clinical presentation for thyroid storm?

A 
Cardiac (tachy, CHF, hypotension, arrhythmia)
Fever
Agitation, anxiety, delirium, psychosis
Stupor, coma
N/V/D, abd pain
Hepatic failure/jaundice
Goiter
Ophthalmopathy, lid lag
Hand tremor
Warm, moist skin
50
Q

diagnosis of thyroid storm?

A

Clinical presentation of severe, life-threatening symptoms
+
Low TSH, high free T4/T3

51
Q

thyroid storm tx?

A

ICU

Meds: 
Beta-blocker
Thionamide 
Iodine solution 
Glucocorticoids 
Bile acid sequestrants

DEFINITIVE THERAPY (ablation therapy)

52
Q

how does BB for thyroid storm work?

A

symptom control

53
Q

how does thionamide for thyroid storm work?

A

block new hormone synthesis

54
Q

how does iodine solution for thyroid storm work?

A

blocks release of thyroid hormone from gland

55
Q

how does glucocorticoids for thyroid storm work?

A

reduces T4 to T3 conversion, promotes vasomotor stability, treat associated related adrenal insufficiency

56
Q

how does bile acid sequestrants for thyroid storm work?

A

decrease enterohepatic recycling of thyroid hormones

57
Q

benign etiology of thyroid nodules?

A

Multinodular goiter
Hashimoto’s thyroiditis
Cysts
Follicular adenomas

58
Q

malignant etiology of thyroid nodules?

A 
Papillary carcinoma
Follicular carcinoma
Medullary carcinoma
Anaplastic carcinoma
Primary thyroid lymphoma
Metastatic carcinoma (breast, renal cell)
59
Q

thyroid nodule cancer concerning factors?

A 
kids, men, adults <30 y/o, >60 y/o
hx of head/neck radiation
hx hematopoeitic stem cell transplant
family hx thyroid cancer
size (larger)
60
Q

what is the most important lab value to evaluate w/ workup of thyroid nodules?

A

TSH

61
Q

what imaging do you order if thyroid nodule found?

A

thyroid ultrasound

62
Q

which is worse “hot or cold” nodule on radioactive scan?

A

COLD

63
Q

next step for solitary nodule with low TSH…

A

thyroid scan

64
Q

next step for solitary nodule with normal TSH…

A

FNA, consider US

65
Q

what type of nodule do you NOT want to bx? (major contraindication)

A

if it is a “HOT” nodule

66
Q

what is a FNA bx?

A

Procedure of choice to evaluate nodules and select surgical candidates

done by palpation or U/s guided in office

large nodules do multiple samples

67
Q

what size of nodule do you do a FNA?

A

≥ 1 cm unless high risk hx then >5mm

68
Q

what findings are worrisome and indicative for FNA?

A

lymph nodes, micro-calcifications, solid masses on u/s

69
Q

Management of benign FNA results?

A

Repeat U/S 6-18 months to assess stability

Growth > 20% - repeat FNA

70
Q

incidence of thyroid carcinoma?

A

Incidence & mortality increase with age

More common in females

Worse prognosis:
< age 20
> age 45
Male gender

71
Q

risk factors for thyroid carcinoma?

A

History of childhood head or neck irradiation

Thyroid cancer in first degree relative

Large nodule size (≥ 4 cm)

72
Q

types of thyroid cancer?

A 
Papillary (~85%)
Follicular (~12%)
Anaplastic (<3%)
Medullary (~1-2%)
Primary thyroid lymphoma (<2%)
Mets from other site
73
Q

Tx for thyroid carcinoma

A 
Surgery (near total thyroidectomy)
TSH Suppression (Levothyroxine)
Radioiodine ablation
Chemotherapy
Palliative external radiotherapy
74
Q

monitoring for thyroid carcinoma post-tx management

A

Serum thyroglobulin level, anti-thyroglobulin antibodies
Neck ultrasound
Serum TSH level
+/- Diagnostic whole body radioiodine scan
MRI, CT, PET as appropriate

75
Q

what is the fx of the parathyroid gland?

A

Parathyroid hormone secretion to help regulate calcium homeostasis

Also helps regulate phosphate

Negative feedback w/calcium sensing receptor on surface of parathyroid cells

76
Q

slide 54

A

54

77
Q

what are examples of parathyroid disease?

A

Hypoparathyroidism

Hyperparathyroidism

78
Q

MC reason for hypoparathyroidism?

A

Acquired, usually occurs post-thyroidectomy

other: autoimmune, congenital

79
Q

Clinical presentation

A

sxs assoc. w/low Calcium

Tetany
Muscle cramps
Caropopedal spasm
Chvostek sign
Trousseau phenomenon
Cataracts
Thin/brittle nails
Dry, scaly skin
AMS
convulsions
80
Q

hypoparathyroidism lab values…

A 
serum calcium (low)
serum phosphate (high)
urinary calcium (low)
alkaline phosphatase (norm)
PTH (low)
Mg (low to norm)
81
Q

Tx for hypoparathyroidism?

A

Emergency treatment for acute tetany:
IV calcium gluconate plus oral calcitriol (wean to oral calcium)
Airway maintenance

82
Q

maintenance tx for hypoparathyroidism?

A

Oral calcium and vitamin D supplementation
Avoid hypercalcemia
2nd line tx: recombinant hPTH

83
Q

Hyperparathyroidism etiology

A

Primary hyperparathyroidism
Secondary or tertiary hyperparathyroidism
Multiple endocrine neoplasia (MEN)

84
Q

etiology for Primary hyperparathyroidism

A 
Parathyroid adenoma (MC)
Parathyroid hyperplasia 
Parathyroid carcinoma (rare)
85
Q

Secondary or tertiary hyperparathyroidism etiology

A
  1. Chronic renal failure
    (Hyperphosphatemia and ↓renal vitamin D production → ↓ ionized calcium, which stimulates the parathyroids)
  2. Renal osteodystrophy
86
Q

clinical presentation of Hyperparathyroidism

A

Asymptomatic hypercalcemia

“bones, stones, abdominal groans, and psychiatric moans”

87
Q

clinical presentation of hyperparathyroidism?

A 
Renal
MSK
GI
Neurologic
CV
88
Q

diagnostics for hyperparathyroidism?

A

Elevated calcium
Elevated serum PTH level
Urinary calcium excretion

89
Q

Tx for hyperparathyroidism?

A

Surgical resection is definitive = Parathyroidectomy

Conservative treatment:
Physical activity 
Drink adequate fluids 
Avoid lithium and HCTZ
Restrict calcium intake to 1000 mg/day
Vitamin D 400-600 IU daily
Monitor
90
Q

conservative tx of of Primary hyperparathyroidism?

A

IV bisphosphonates can temporarily ↓ hypercalcemia and treat bone pain

Zoledronic acid (Reclast)

91
Q

Secondary or tertiary hyperparathyroidism conservative tx?

A

Cinacalcet (Sensipar), paricalcitol (Zemplar)

Foundations III- Endocrine (5 decks)

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