Thyroid And Parathyroid 🦋 Flashcards
How will someone with hypothyroidism present?
Fatigue, weakness
Cold intolerance
Weight gain
Cognitive dysfunction (“fog”)
Constipation
Pubertal delay
Menstrual changes
Myalgia, arthralgia
Decreased hearing
Depression
How will hypothyroidism affect blood pressure?
Diastolic BP increases
How does hypothyroidism affect your skin, hair and nails?
Dry skin
Thinning hair
Brittle nails
Eyebrows fall out
How will hypothyroidism affect the face and neck?
Puffy facies
Periorbital edema
Tongue enlargement
Goiter**
Loss of eyebrows
How will hypothyroidism affect DTRs?
Delayed
Primary hypothyroidism (aka the gland itself is messed up):
TSH:
Free T4/T3:
TSH: high
Free T4/T3: low
Central hypothyroidism:
TSH:
Free T4/T3:
TSH: low or normal
Free T4/T3: low or normal
Subclinical hypothyroidism
TSH:
Free T4/T3:
TSH: high
Free T4/T3: normal
What is primary hypothyroidism?
There is something wrong with the thyroid gland itself
What is central hypothyroidism?
Something is wrong with the pituitary or hypothalamus and they’re not making TSH or TRH
What 2 antibodies would you expect to see high levels of in Hashimoto’s Thyroiditis?
Anti Thyroid Peroxidase antibody (TPO Ab)
Antithyroglobulin Antibody (TgAb)
In what two conditions may Anti Thyroid Peroxidase antibody (TPO Ab) be elevated?
Hashimotos Thyroiditis***
Grave’s disease
What antibody is used to monitor thyroid cancer?
Antithruglobulin Antibody (TgAb)
In what two conditions may Antithyroglobulin Antibody (TgAb) be high?
Hashimoto’s thyroiditis ***
Graves’ disease
Is TSH Receptor Antibody (TRAb) seen in Underactive or Overactive thyroid?
Overactive
Will TSH Receptor Antibody (TRAb) be positive in Hashimotos?
May or may not be
Have nooo idea what this slide meant
Will TSH Receptor Antibody (TRAb) be positive in Graves’ disease
Yes
What is the main cause of primary hypothyroidism
Hashimotos
What is the most common cause of hypothyroidism?
Hashimotos
What causes HAshimotos?
Autoimmune attack on thyroid that causes a gradual loss of thyroid function.
Caused by a combo of genetic and environmental factors
What two syndromes are associated with a higher risk for hashimotos?
Down syndrome
Turner’s syndrome
What is Hashitoxicosis?
It is transient HYPERthyroidism that happens at the beginning inflammation of Hashimoto’s.
(Thyroid dumps out a ton of thyroid hormones before becoming hypo)
What are some precipitating factors that may cause hashimotos to develop?
Stress
Pregnancy*
Infection
Iodine intake
Radiation exposure
Do women or men get hashimotos more?
Women 7x more
How do you treat hypothyroidism?
Synthetic Thyroxine (T4)
=Levothyroxine (Synthroid, Levothroid, Levoxyl)
What is the goal of synthetic T4 replacement therapy?
Maintain a euthyroid state (0.5-5.0), relieve sx, and decrease goiter size
How do you dose Levothyroxine?
Start at 1.6 mcg/kg/day and then titrate up or down at the 6 week follow up
Who needs a lower dose of Levothyroxine ?
Elderly
Patients with heart problems
What time of day do patients need to take their Levothyroxine?
Empty stomach one hour before breakfast**
Need to absorb ALL of it
Do we need to monitor TSH and free T4 while a patient is on Levothyroxine ?
Yes of course you do
What is subclinical hypothyroidism?
Elevated TSH with normal T4
How will a patient with subclinical hypothyroidism present?
Non-specific symptoms like “Fatigue”
WHat can happen if you don’t treat subclinical hypothyroidism?
CV disease
Fatty liver
Miscarriage and Low birth weight babies**
WHat should you do if your patient looks like they have subclinical hypothyroidism (i.e., high TSH, normal T4)?
Repeat TSH and T4 in 1-3 months to confirm the diagnosis
BUT if they are pregnant or on fertility treatment, you need to repeat it IMMEDIATELY
When do you need to give treatment for subclinical hypothyroidism?
If TSH is 10 or more, definitely treat
If TSH is 4.5-9.9, treatment is controversial based on age and symptoms
And of course, if they are pregnant or doing fertility treatment
What is the biggest complication of hypothyroidism?
Myxedma Coma
What is Myxedema coma?
Hypothermia, bradycardia, severe hypotension, seizures, coma.
Brought on by cold weather or illness.
Who usually gets myxedema coma?
Old patients who have had long-standing profound hypothyroidism
How do you treat myedema coma?
IV bolus T4
IV Hydrocortisone
Hypertonic saline
Supportive
Is hyperthyroidism more comon in women or men
Women 5x more
Especially older women and smokers
What usually causes hyperthyroidism in younger women?
Graves’ disease
What usually causes hyperthyroidism in older women?
Toxic nodular goiter
How will someone with hyperthyroidism present?
They will look like they’re on speed:
Fast HR
AFib**
Weight loss
Sweating
Stare and lid lag**
Exopthalmos**
Diarrhea*
Insomnia, restlessness
Tremor
Peeing a lot
Hyperthyroidism
TSH:
Free T4/T3:
TSH: low
Free T4/T3: high
Subclinical hyperthyroidism:
TSH:
Free T4/T3:
TSH: low
Free T4/T3: normal
When you suspect something might be wrong with your patient’s thyroid, what lab test do you order?
“TSH with Reflux Free T4”
Which means: check TSH first, and if that is abnormal, then check free T4
Why do we check “Free” T4
Because T4 is 99% protein bound
When would you order a “total” T4
Never, there is no use
What immunoglobulins will be positive in Grave’s disease?
Thyroid-Stimulating Immunoglobulins (TSI)**
Thyroid-binding Inhibitory Immunoglobulin (TBII)
Will TSH Receptor Antibody (TRAb) be positive in Graves’ disease?
Yes
Will Anti Thyroid Peroxidase antibody (TPO Ab) be elevated in BOTH Hashimotos and Graves?
Yes, but it will be much higher in Hashimotos
Will Anti Thyroglobulin Antibody (TgAb) be elevated in BOTH Hashimotos and Graves?
Yes, but it will be much higher in hashimotos
What will cause normal-high radioiodine uptake test results?
Anything that causes increased de novo synthesis of thyroid hormone:
Graves’ disease
Hashitoxicosis
Toxic adenoma or toxic nodular goiter
Autonomous nodules (HOT)🔥🔥**
Iodine deficiency
What will cause a nearly-absent radioiodine uptake scan?
Exogenous Thyroid hormone aka taking Levothyroxine
Nonfunctioning nodules- COLD❄️❄️***
Thyroiditis (subacute, painless, radiation, iodine-induced)
If you see a non functioning COLD ❄️ nodule on a thyroid uptake and scan, what do you need to consider?
You should think that it is cancerous and do a Fine Needle Aspiration
What increases the risk of developing Graves’ disease?
Genetics
Stress
Smoking
Thyroid injury
What is the most common feature of Graves’ disease?
hyperthyroidism
How will a patient with Graves’ disease present?
Graves ophthalmopathy**: lid retraction, lid lag, stare, proposes, periorbital edema
Pretibial Myxedema** skin on shins is weird
Non-nodular goiter
Other sx of hyperthyroidism
If someone has Low TSH and Elevated Free T4/T3, as well as TRAb antibodies, and Orbitopathy, what is the next test you need to do?
Thyroid uptake and scan
What is a Toxic Multinodular Goiter?
A goiter with multiple nodules that is caused by hyperplasia of follicular cells.
What is the 2nd most common cause of hyperthyroidism?
Toxic Multinodular Goiter (MNG)
“Toxic” means overactive
What is a toxic adenoma?
A nodule with increased radioiodine uptake
What are some concerning symptoms when someone has toxic adenoma or toxic MNG?
Cough
Dyspnea
Dysphagia
OBSTRUCTIVE SYMPTOMS* needs IMEMDIATE TREATMENT
If you look at a thyroid uptake and scan and you see Focal areas of increased radioiodine +/- “cold spots,” what do you have
Toxic adenoma or toxic MNG
??????
If you are unable to differentiate a toxic adenoma or toxic MNG from Grave’s disease, what should you look at?
Antibodies
How do you treat hyperthyroidism (other than surgery/ablation)?
Atenolol 25-50mg daily****
Aspirin*** to prevent clots from AFib
Thionamides for severe sx: (Methimazole or PTU)
Avoid strenuous activity (HR and BP are already too high)
What are the two thinoamides?
Methimazole
Propylthiouracil (PTU)- preferred in pregnancy🤰🏻
What are thionamides taken for?
hyperthyroidism
What is the first line definitive treatment for hyperthyroidism?
Radioiodine ablation
How is radioiodine ablation done?
Patient takes a thinoamide (PTU/Methimazole) for awhile
Takes a single dose of I131 (radioactive iodine)
=thyroid dead
If you get a a radioiodine ablation, who do you need to avoid for 3 weeks
Childern
Pregnant women
Radioiodine ablation is contraindicated for:
Pregnant women
Women who want to get pregnant in the next few years and active ophthalmopathy (???)
When would we do surgery for hyperthyroidism (instead of radioiodine ablation)
Toxic adenoma/MNG***
Large goiter with obstructive sx
Pts with moderate-severe ophthalmopathy
What are the complications of hyperthyroidism?
Permanent exopthalmos
Osteoporosis
Stroke, AFib, CHF
Thyroid storm**
Is a thyroid storm an emergency?
Yes
What can cause thyroid storm?
Major stress*
Surgery
Radioiodine ablation**
Iodine contrast
Inadequate treatment
What are the symptoms of a thyroid storm?
Vomiting/diarrhea
Confusion/delirium
Tachyarrythimas
Dehydration
Fever
Coma
How do you treat thyroid storm?
Fluid replacement
Anti-arrhythmia meds
IV PTU
Electrolyte stabilization
What are the other names for subacute thyroiditis?
Granulomatous
De Quervain’s
Giant cell thyroiditis
What happens before subacute thyroiditis?
Viral Illness or URI**!!!!!!!!!!*!!!**!
Who usually gets subacute thyroiditis?
Young to middle-age women
How will a pt with subacute thyroiditis present?
Acute, SEVERELY painful glandular enlargement (goiter)đź’Ąđź’Ąđź’Ą***
Radiating pain to jaw, chest, etc
Fever, fatigue, malaise, anorexia, myalgia
True or false:
Subacute thyroiditis is an inflammatory process
True
~~~~INFLAMMATORY~~~~~~
What is the progression of subacute thyroiditis?
Hyperthyroid
Euthyroid
Hypothyroid
Recovery (Euthyroid)
This is a PREDICTABLE progression of phases
**THIS WAS CIRCLED IN BLUE**
How do you treat subacute thyroiditis?
NSAIDs/Aspirin
Prednisone
We DON’T block the thyroid or give levothyroxine: all we do is try to bring down inflammation
Who needs to be screened for thyroid disorders?
EVERYONE over 60***
Goiter
Hx of autoimmune disease
Prior radioactive iodine therapy
Family hx of thyroid disease
Certain meds: lithium**, amiodarone*, aminoglutethimind, interferon a, thalidomide, betaroxine, stavudine
(Probably only need to know lithium and amiodarone)
What are the 4 types of thyroid cancer in order of most common to least common***
Papillary 76%
Follicular 16%
Medullary 4%
Anaplastic 1% (VERY aggressive)
So you find a thyroid nodule. Now what do you need to know/
Is it cancer?
Is it causing thyroid dysfunction?
A thyroid nodule in what groups of people should make you very concerned about cacner?
Kids
Men**
Younger than 30
Older than 60
Head/neck radiation
Stem cell transplant
Family hx of thyroid cancer
When is a thyroid nodule more concerning: in a man or in a woman?
Man
Women get benign nodules alll the time so we are less concerned
How do you work up a thyroid nodule?
- History and exam to determine high or low risk
- Measure TSH
- Thyroid ultrasound (if concerning, ~then~ do FNA) ???
- Thyroid uptake and scan
- If nodule is COLD- do fine needle aspiration
- If nodule is HOT- DO NOT stick a needle in it!!
(This slide was sort of unclear!! I’m sorry!)
(Hot/Cold) nodules are NOT cancer
Hot
What happens if you stick a needle in a Hot nodule?
You will cause thyroid storm**
As TSH levels go up, the likelihood of cancer (increases/decreases)
Increases
What findings on a thyroid ultrasound are more likely to be malignant?
Hypoechoic**
Microcalcifications**
> 1cm and solid/hypoechoic
Irregular margins
Tall>wide
Extracapsular growth
Associated cervical nodes
What findings on a thyroid ultrasound are more likely to be benign?
“Purely cystic” *****
Colloid
<1 cm without other suspicious characteristics
Hypoechoic and Microcalcifications on a thyroid ultrasound should make you think (malignant/benign)
Malignant
“Purely cystic” and “Colloid” on a thyroid ultrasound should make you think (Malignant/Benign)
Benign
What is the procedure of choice to evaluate nodules and to select surgical candidates?
Fine Needle Aspiration Biopsy
What is the most common result of a FNA biopsy?
Benign (60-75%)
Is thyroid cancer more common in men or women
Women
What ages have a worse prognosis for thyroid cancer?>
Younger than 20
Older than 45
Do men or women have a worse prognosis of thyroid cacner
Men
What are the 2 types of “Differentiated” thyroid cancer?
Papillary
Follicular
*******
Which kind of thyroid cancer is “Undifferentiaed”?
Anaplastic
Which has the highest cure rates:
Differentiated or Undifferentiated Thyroid Cancer
Differentiated
What is the prognosis like for Anaplastic thyroid cacner
Poor
*****
Which type of thyroid cancer is “Familial”?
Medullary
***
Medullary Thyroid cancer is “Familial.” Can it also occur spontaneously?
Yes
**
What genetic marker should you test for when you discover medullary thyroid cancer?
RET mutations
What is the treatment for Thyroid cancer?
Surgery- total thyroidectomy
Radioiodine Ablation after surgery
Thyroid hormone suppression to prevent further growth- levothyroxine at lower therapeutic thresholds*****
Radiation/chemotherapy
Hyper or Hypo thyroidism:
Brittle nails
Hypothyroidism
Hyper or Hypothyroidism:
Cold intolerance
Hypothyroidism
Hyper or Hypothyroidism:
Depression
Hypothyroidism
Hyper or Hypothyroidism:
Increased Appetite
Hyperthyroidism
Hyper or Hypothyroidism:
Hand tremors
Hyper
Hyper or Hypothyroidism:
Frequent bowel movements
Hyper
🧻
Hyper or Hypothyroidism:
Sleeplessness
Hyper
What causes PTH to be released?
Low serum calcium
What is the MOT common cause of hypoparathyroidism?
Damage after a thyroidectomy🔪
*****
What are 2 other causes of Acquired hypoparathyroidism, other than damage during surgery?
Neck irradiation
Alcoholism
Which the most common cause of hypoparathyroidism:
Acquired
Autoimmune
Congenital
Acquired (Due to damage during surgery)
If you have hypoparathyroidism, what will your levels be:
Calcium:
PO4:
Calcium: Low
PO4: HIGH**
(Even though there’s less resorption of phosphate from the bone and gut, there’s a lot more phosphate reabsorption in the kidney, and the kidney always wins)
What are the neuromuscular symptoms of hypoparathyroidism?
Tetany
Muscle twitching
Carpopedal spasms
Seizures
Weakness
Laryngospasm
Paresthesia
All due to hypocalcemia
What are the cardiac symptoms of hypoparathyroidism?
Heart failure
Hypotension
Arrhythmia
Prolonged QT
Chvostek’s Sign and Trousseau’s sign will be positive in what condition?
Hypocalcemia****
Will Chvostek’s and Trousseau’s sign be positive in Hyper or hypoparathyroidism
Hypoparathyroidism (causes low calcium)
What is Chvostek’s sign?
Spasm of the facial muscles following facial nerve tapping
What is Trousseau’s sign?
Muscle spasm of the hand and wrist when you inflate a BP cuff around the upper arm
What do you think this person has:
Ectopic calcification
Parkinsonism (jerky, spasms)
Dementia
Cataracts
Shitty teeth
Dry coarse skin
Brittle nails
Hair loss
Renal stones
Hypoparathyroidism
Expected lab results for hypoparathyroidism:
PTH
Calcium
Magensium
Vit D
Phosphate
PTH: Low
Calcium: Low
Magnesium: Low
Vitamin D: normal/low
Phosphate: HIGH!!!!!!!**!!!
How do you treat emergency hypoparathyroidism?
IV Calcium Gluconate
Airway maintenance (often need to be intubated due to all the spasms etc)
How do you treat hypoparathyroidism once they are out of the “danger zone?” (No more tetany, seizures, prolonged QT)
Oral calcium 1-2 g/day
Vitamin D
Magensium if needed
True or False:
We treat hypoparathyroidism with PTH replacement
False. We replace calcium
What is the MOST common cause of PRIMARY hyperparathyroidism?
Parathyroid adenoma**!!! ON TEST
What are three possible causes of primary hyperparathyroidism?
Parathyroid adenoma **MOST COMMON
Parathyroid hyperplasia
Parathyroid carcinoma (rare)
What is the main cause of secondary or teritiary hyperparathyroidism?
Chronic renal failure!!**!*
Hyperphosphatemia and low renal Vitamin D production —> low calcium, which stimulates the parathyroid
Expected lab values for hyperparathyroidism:
PTH:
Calcium:
Phosphate:
Magnesium:
PTH: high
Calcium: High
Phosphate: LOW**
Magensium: high
What is the most common presentation of hypercalcemia?
Asymptomatic!!!
*****
Was bold, large, and had stars on it**
(Even though we have that little bones stones moans and groans thing for hyperparathyroidism)
What does condition does “Bones, Stones, Abdominal Moans, Thrones, and Psychiatric Groans” refer to?
Hyperparathyroidism
What are the symptoms of hyperparathyroidism that “Bones, Stones, Abdominal Moans, Thrones, and Psychiatric Groans” refers to?
Bones: arthralgia, bone pain*** MAIN SYMPTOM
Stones: kidney stones and diabetes insipidus
Abdominal moans: vague GI sx
Psychiatric groans: psychosis, depression delirium
Thrones: constipation and polyuria
Lab values for Primary Hyperparathyroidism:
Calcium:
Phosphate:
PTH:
\Calcium: high**
Phosphate: low-normal**
PTH: high
Lab values for secondary hyperparathyroidism
Calcium:
Phosphate:
PTH:
Calcium: LOW**
Phosphate: High if due to renal, and Low if due to vitamin D
PTH: High
What diagnostic tests do you need to do if you suspect your patient has hyperparathyroidism?
DEXA scan- PTH is chewing up their bones!
Kidney function- 24 hr urine and imaging
Parathyroid ultrasound
Sestamibi parathyroid scan (radioactive) with CT scan- noooooo fuckin clue what this is
What is the definitive treatment for hyperparathyroidism?
Parathyroidectomy
might need lifelong calcium supplementation after
What is the conservative treatment for hyperparathyroidism (aka you’re not doing surgery)
Physical activity- keep bones strong
Hydration- no kidney stone
Avoid lithium and HCTZ- cause high calcium
Restrict calcium intake to 1g/day
Vit D
IV BisphosponatesProtects bones from PTH
Whenever you measure PTH levels, you must ALWAYS measure ________ as well
Calcium levels**
Hyperparathyroidism
Calcium:
PTH:
Calcium: high
PTH: high
Hypoparathyroidism
Calcium:
PTH:
Calcium: low
PTH: low
Hypercalcemia of malignancy
Calcium:
PTH:
Calcium: high
PTH: low
Secondary Hyperparathyroidism (renal disease)
Calcium:
PTH:
Calcium: low
PTH: High
