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Endocrinology > Thyroid Disorders > Flashcards

Thyroid Disorders Flashcards

1
Q

Hypothyroidism and Hyperthyroidism thyroid hormone levels?
TSH
T4
T3

A

Hypothyroidism
TSH- high
T4- Low
T3- low

Hyperthyroidism
TSH-low
T4- high
T3- low

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2
Q

What is a goiter?

Whats the most common cause of goiters and what is the mechanism?

A

Abnormal growth of the thyroid gland

Iodine deficiency most common cause world wide—mechanism?

Iodine rich foods…..sea vegetables, yogurt, cheese, navy beans, strawberries, potatoes, shellfish, eggs, shrimp, sardines

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3
Q

What are the most common causes in the US?

3

A
  1. Multinodular goiter (most common in elderly)
  2. Chronic autoimmune (Hashimoto’s) thyroiditis
  3. Grave’s disease
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4
Q

Goiter Obstructive Symptoms

3

A
  1. Monotone voice
  2. Dysphagia (difficulty swallowing)
  3. Tracheal compression
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5
Q

Test for Diagnosis for goiter?

if this test is high what should we measure?

Most common cause?

If this test is low what should we do? 3

What is the most common disease?

A

Obtain TSH:

If high—measure serum free T4—Diagnosis?

Most common cause is Hashimoto’s thyroiditis

  1. If low—measure free T4, serum total T3—Diagnosis?
  2. Consider Ultrasound
  3. Need 24-hour radioiodine uptake scan

Multinodular goiter/Grave’s disease most common

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6
Q

Most common cause of hypothyroidism?

There are three types. What are they?

A

Most common cause is Hashimoto’s Thyroiditis

Three types – Primary, Secondary and Tertiary

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7
Q

Primary Hypothyroidism causes?

7

A
  1. Iodine deficiency
  2. Autoimmune: Hashimoto’s
  3. Iatrogenic: Iodine-131 therapy, thyroidectomy
  4. Post Partum Thyroiditis
  5. Drug induced: Lithium, Amiodarone, antithyroid drugs
  6. Congenital: agenesis, dysgenesis, hypoplastic
  7. Adult onset: normal aging
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8
Q

Secondary Hypothyroidism causes?

5

A
  1. Neoplasm
  2. Surgery
  3. Post partum necrosis
  4. Cushing’s
  5. Radiation
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9
Q

Tertiary Hypothyroidism causes?

3

A
  1. Hypothalamus dysfunction
  2. Hemochromatosis
  3. Sarcoidosis
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10
Q

Things you will find in the history for hypothyroidism?

10

A
  1. Fatigue
  2. Cold intolerance
  3. Weakness
  4. Lethargy
  5. Weight gain
  6. Constipation
  7. Myalgias
  8. Arthalgias
  9. Menstrual irregularities
  10. Hair loss
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11
Q

Physical findings for hypothyroidism?

7

A
  1. Dry, course skin
  2. Hoarse voice
  3. Brittle nails
  4. Periorbital, Peripheral edema (myxedema)
  5. Delayed reflexes
  6. Slow reaction time
  7. Bradycardia
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12
Q

Diagnosing Hypothyroidism
The thyroid-stimulating hormone (TSH) level is elevated. What does this indicate?
2

A
  1. indicating that thyroid hormone production is insufficient to meet metabolic demands
  2. free thyroid hormone levels are depressed
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13
Q

Can have “sub-clinical hypothyroidism.” What will your lab levels look like?
3

A

T3, T4 are within normal limits but TSH mildly elevated

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14
Q

Hypothyroidism treatment?

A

Thyroid hormone: usually 100 to 200 mcg daily
Can start with 50-100mcg QD

Levothyroxine (T4) {Synthroid}
-monitor TSH for response

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15
Q

Hypothyroidism treatment in the elderly?

A

In the elderly, start with 25-50 mcg and increase by 25 mcg every 2-3 weeks

Levothyroxine (T4) {Synthroid}
-monitor TSH for response

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16
Q

Monitoring Thyroid Function:
Patients with an intact hypothalamic-pituitary axis how should we monitor?

How about patients with a pituitary insufficiency?

A

Follow with serial TSH measurements

Measurements of free T4 and T3

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17
Q

How often should we monitor hypothyroidism?

A

8-12 weeks

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18
Q

We should have stable dosing until the 7th decade. Why would we have to adjust it then?

A

With age, thyroid binding may decrease, and the serum albumin level may decline. In this setting, the Levothyroxine dosage may need to be reduced by up to 20 percent

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19
Q

Hypothyroidism
syndromes?
3

A

Hashimotos Thyroiditis
Myxedema
Subclinical Hypothyroidism

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20
Q

Whats the most common form of thyroiditis?

Whats another name for it?

What disease can it be associated with?

A

Hashimoto’s Thyroiditis

AKA chronic lymphocytic thyroiditis

It can be associated with non-Hodgkins lymphoma (NHL)

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21
Q

What kind of disorder is hashimoto’s?

When in life does it usually occur?

Where is this the most common cause of hypothyroidism?

A

Autoimmune disorder

Usually occurs between the third and sixth decade

Most common cause of hypothyroidism in areas where there is sufficient iodine

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22
Q

Hashimoto’s Thyroiditis
has what thyroid antigens that cause the autoimmune disease? 3

Precipitating factors for hashimoto disease? 4

A
  1. Thyroglobulen (Tg)
  2. Thyroid peroxidase (TPO)
  3. The thyrotropin (TSH) receptor
  4. Infection
  5. Stress
  6. Sex steroids, pregnancy
  7. Radiation exposure
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23
Q

Most common signs and symptoms of Hashimoto’s?

7

A
  1. Painless goiter
  2. Fatigue
  3. Muscle weakness
  4. Weight gain
  5. Feeling of fullness in the throat
  6. Neck pain, sore throat, or both
  7. Low-grade fever
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24
Q

Thyroid Scan-iodine marked with radioactive tracer. What does this test detect?

A

camera can detect how much of the tracer is taken up by the thyroid

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25
Q

Labs to do for Hashimotos?
4

Imaging to do for Hashimotos?
2

A
  1. TSH,
  2. Free T4
  3. TPOAb (anti-thyroid peroxidase antibody)
  4. TGAb (anti-thyroglobin antibodies)
  5. ultrasound to establish goiter size
  6. Radioiodine uptake
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26
Q

Treatment for Hashimoto’s?

What should we monitor?

A

Thyroid hormone replacement:
Levothyroxine (T4) (Levothyroid, Synthroid)

Monitoring of TSH is best and most reliable

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27
Q

Levothyroxine (T4) (Levothyroid, Synthroid) for patients with:
under 60 w/o CAD?
pregnant women?
over 60 or pts with CAD?

A

50-100mcg daily – under 60 w/o CAD

100-150mcg daily – pregnant women

12.5-50mcg daily – over 60 or pts with CAD

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28
Q

Mild thyroid failure is a common disorder that frequently progresses to overt hypothyroidism. What are strong predictors of this?
4

A
  1. Anti-TPO antibodies
  2. TSH >20
  3. Radioiodine ablation Hx (Grave’s Disease)
  4. Other radiation therapies
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29
Q

Populations at Risk for
Subclinical Hypothyroidism
5

A
  1. Women
  2. Prior history of Graves disease or postpartum thyroid dysfunction
  3. Elderly
  4. Other autoimmune disease
  5. Family history of
    - Thyroid disease
    - Pernicious anemia
    - Type 1 Diabetes mellitus
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30
Q

Subclinical Hypothyroidism
Treatment and why?

In the absence of positive antibodies?

When should we consider treatment without positive antibodies?
2

A

Levothyroxine therapy is recommended in those patients with positive antibodies because they are at greatest risk to progress to overt hypothyroidism

Asymptomatic TSH less than 10mU/L - follow their TSH

TSH>10mU/L
TSH less than 10mU/L who are pregnant or have manifestations such as goiter, lipid abnormalities, anovulatory menses

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31
Q

Myxedema is thought to be related to what?

A

thought to be related to connective tissue proliferation in reaction to increased to TSH levels

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32
Q

The Myxedem patient will usually have a history of what?

WHo does it usually develop in?

Symtpoms? 4

A

hypothyroidism

Develops in older adults

  1. Droopy eyelids
  2. Lethargy, fatigue, mental sluggishness
  3. Decreased reflexes
  4. Mucopolysaccharide infiltration of the dermal space
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33
Q

Mucopolysaccharide infiltration of the dermal space in Myxedema causes what?
3

A
  1. Facial puffiness
  2. Periorbital edema
  3. Non-pitting pretibial edema
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34
Q

Treatment for Myxedema?

2

A
  1. Thyroid hormone replacement
    Levothyroxine (T4) (Levothroid, Synthroid)
  2. Monitor TSH
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35
Q

Hyperthyroidism is also known as?

What is the most common cause?

A

AKA Thyrotoxicosis or Toxic diffuse goiter

The most common cause is Grave’s Disease.

36
Q

Pathology of Graves Disease?

Describe the onset?

WHo does it occur in most commonly?

A
  1. Auto-immune d/o….appears suddenly
  2. Body produces antibodies to the receptor for TSH

It occurs most commonly in women between the ages of 20 and 40.

37
Q

Common etiology of hyperthyroidism? 3

Less common etiologies of hyperthyroidism? 3

Rare etiologies?
5

A

Common:

  1. Graves’ Disease
  2. Toxic Adenoma (solitary)
  3. Toxic Multinodular Goiter

Less common:

  1. Subacute thyroiditis
  2. Hashimoto’s thyroiditis with transient hyperthyroid state
  3. Postpartum thyroiditis

Rare:

  1. Struma ovarii
  2. Hydatiform mole
  3. Metastatic thyroid cancer
  4. TSH secreting pituitary tumor
  5. Pituitary resistance to T3 and T4
38
Q

Hyperthyroidism that cannot be correlated to the endocrine system is usually what?

A

a malignancy, i.e small cell carcinoma or carcinoid

39
Q

Hyperthyroidism symtpoms?

7

A
  1. Nervousness
  2. Diaphoresis
  3. Heat intolerance
  4. Palpitations
  5. Fatigue
  6. Weight loss
  7. Frequent bowel movements
40
Q

Hypertyroidism signs?

9

A
  1. Tachycardia
  2. Goiter
  3. Skin changes (pretibial myxedema)
  4. Tremor
  5. Eye signs (exophthalmos)
  6. Conjunctival inflammation,
  7. Extraocular muscle dysfunction
  8. Lid lag
  9. Osteoporosis
41
Q

Laboratory findings in Hyperthyroidism?

4

A
  1. TSH - Low
  2. Free T4 - High
  3. TSI (thyroid-Stimulating Immunoglobulin) may be elevated in Graves’ Disease
  4. Radioactive Iodine uptake ?
42
Q

Hyperthyroid Treatment? 2

MOA?

A

Anti-Thyroid Drugs (thioamides):

  1. Methimazole (Tapazole) 5-15mg/day (once daily)
  2. Propylthiouracil (PTU) 100-150mg/day

Both act by inhibiting iodine orgnaification

43
Q

Side effects of Anti-Thyroid Drugs (thioamides):

Common? 4

Rare? 4

A

Common:

  1. pruritus,
  2. arthralgia’s,
  3. GI distress,
  4. metallic taste

RARE:

  1. agranulocytosis,
  2. hepatitis (PTU),
  3. aplastic anemia,
  4. thrombocytopenia
44
Q

What labs would you get prior to starting Side effects of Anti-Thyroid Drugs (thioamides)?
3

A

CMP (LFT)
CBC
The usual workup

45
Q

Whats the most widely reccommended permanent treatment of hyperthyroidism?

80-90% of injected I-131 is absorbed by the hyperplastic, toxic thyroid gland within?

What can this treatment worsen transiently?

Post treatment precautions?

Pretreatment precautions?

Most common side effect?

A

Radioactive Iodine Treatment

within 1 day of injection

Can worsen Grave’s ophthalmopathy transiently

Post treatment precautions:
Limit exposure to others for one week

Pretreatment:
Stopping thyroid hormone replacement…high levels of TSH encourage uptake of the RI by the thyroid

Most common side effect ? Yes, hypothyroidism

46
Q

What is a permanent cure for hyperthyroidism?

How often is it done?

Side effects? 2

A

Surgical Removal of the Gland

Used about 1% of the time

PTU
High concentration iodides

47
Q

Symptomatic Treatment
of hyperthyroidism?

For patients with temporary forms of hyperthyroidism what should we do?

When should we discontinue treatment?

A
  1. Beta Blockers – Propanolol:
    Initial dose: 40 mg orally twice a day
    Maintenance dose: 120 to 320 mg/day

beta blockers may be the only treatment required

Discontinue with symptom resolution

48
Q

Hyperthyroidism syndromes?

5

A
  1. Grave’s Disease
  2. Multinodular Goiter
  3. Factitious hyperthyroidism
  4. Thyroid Storm
  5. Thyroiditis
49
Q

What is an Organ-specific autoimmune disorder that causes hyperthyroidism?

What is the Pathology behind this disease?

A

Grave’s disease

The body creates circulating antibodies for the thyroid

50
Q

What are the common autoimmune antibodies in grave’s disease?
3

A
  1. antithyroperoxidase (anti-TPO)
  2. antithyroglobulin (anti-TG) antibodies
  3. thyroid-stimulating immunoglobulin (TSI)
51
Q

The autoantibody TSI is directed towards what in the body?

What does it act as?

What does it bind to and what does this cause?

A

TSI is directed toward follicles of the thyroid-stimulating hormone (TSH) receptor and acts as a TSH-receptor agonist

Similar to TSH, TSI binds to the TSH receptor on the thyroid follicular cells to activate thyroid hormone synthesis and release, and thyroid growth (hypertrophy)

52
Q

Grave’s disease Tetrad of symptoms?

4

A
  1. Nontender, smooth, symmetric thyroid enlargement
  2. Thyrotoxicosis – hyperthyroid state
  3. Exopthalmosis
  4. Pretibial myxedema
53
Q

Grave’s disease physical exam findings? 2

Older individuals may have apathetic hyperthyroidism. What does this cause?
6

A

Extremely thin digits
Excess sweating

  1. Flat affect
  2. Weight loss
  3. Emotional lability
  4. Atrial fibrillation
  5. CHF
  6. Muscle weakness
54
Q

Grave’s disease labs?
2

What is the most specific autoantibody for autoimmune thyroiditis?

What are tests that can also help establish the diagnosis?
2

A

TSH-low
T4-high

an enzyme-linked immunosorbent assay (ELISA) for TSHR-Ab levels

  1. TSI, if elevated, helps establish the diagnosis of Graves disease
  2. RAIU (Radioactive Iodine Uptake)
55
Q

RAIU (Radioactive Iodine Uptake) would look like what?

A

Much more uptake so the image would be much larger and darker

56
Q

Treatment of Grave’s disease?

5

A

Antithyroid drugs –

  1. Propylthiouracil (PTU) and
  2. Methimazole (Tapazole) for at least 12 to 18 months.
  3. Beta Blockers – Propanolol (Inderal)
  4. Radioactive Iodine (some physicians use steroids with RAI due to worsening of exophthalmos with use of RAI.)
  5. Surgery
57
Q

What do beta blockers help with for grave’s disese?

2

A
  1. Prevents the peripheral conversion of T4 to T3

2. Decreases Blood Pressure and rate of the heart

58
Q

Multinodular Goiter
“Plummers Disease”
is characterized by what?

Disease usually in what age groups?

Common in what kind of areas?

A

Characterized by functionally autonomous nodules

Disease of older individuals

Common in areas of iodine insufficiency

59
Q

Pathology of Multinodular Goiter
“Plummers Disease”?

What may they present with?

A

Caused by hyperplasia of the follicular cells whose activity becomes independent of TSH
May present with subclinical hyperthyroidism

60
Q

How do we diagnosis Pathology of Multinodular Goiter
“Plummers Disease”?
4

A

Diagnosis:

  1. suppressed TSH
  2. markedly elevated T3
  3. moderately elevated T4
  4. thyroid scan with multiple functioning nodules
61
Q

Factitious Hyperthyroidism
is also called what?

What is it caused by?

What kind of people could this be seen in? 3

T3 and T4 are ? and TSH is ? as is serum thyroglobulin concentration

A

AKA thyrotoxicosis factitia

  1. Ingestion of Levothyroxine by euthyroid patients
  2. May be iatrogenic
May be seen in 
1. health care workers, 
2. dieters, 
3. body builders…Munchausen syndrome
Usually an attempt to lose weight

high
low

62
Q

Thyrotoxicosis will have what kinf of T3/T4 levels?

What can it be caused by? 2

Is there a history of hyperthyroidism?

A

Elevated T3 and/or T4

  1. Sometimes due to inflammation of the thyroid
  2. Can occur after ingestion of exogenous hormone (i.e. buying levothyroxine over the counter in Mexico as a “weight loss agent”

Usually no history of hyperthyroid condition

63
Q

What is a thyroid storm and what are its precipitating factors?6

A

Life-threatening crisis…..one of those rare endocrine emergencies

Precipitating factors:

  1. Hyperthyroidism
  2. Stress
  3. Infection (usually respiratory)
  4. Diabetic ketoacidosis
  5. Physical or emotional trauma
  6. Manipulation during thyroidectomy
64
Q

Thyroid storm clinical features?

4

A
  1. Very high fever
  2. Cardiovascular effects
  3. CNS effect
  4. Nausea & vomiting
65
Q

Thyroid storm Rapid diagnosis and treatment?

5

A
  1. Peripheral cooling (cold packs and cooling mattress)
  2. Replace fluids, glucose and electrolytes
  3. Propranolol to block effects of T4 on cardiovascular function
  4. Glucocorticoids to correct adrenal insufficiency and to inhibit peripheral conversion of T4 to T3
  5. Propylthiouracil (PTU) and Methimazole (Tapazole) to block thyroid synthesis
66
Q

What are the three classifications of thyroiditis?

What does it usually present as and what is this due to?

How can it be distinguished from other causes of thyroiditis?

A

Classified as Acute, Subacute and Chronic

Usually presents clinically as hyperthyroidism due to leakage of preformed thyroid hormone, though most patients ultimately develop hypothyroidism

Can be distinguished from other causes of thyroiditis as the RAIU is low

67
Q

Acute Thyroiditis is a rare complication of what?

How does it present? 3

If blood cultures are negative, what may be tried to identify the organism?

How is this usually treated?
2

A

A rare complication of septicemia

Presents with

  1. fever,
  2. redness of the skin over the thyroid and
  3. tenderness** of the thyroid

aspiration of the thyroid gland

Usually treated with IV antibiotics, though occasionally I&D of the gland may be required

68
Q

Subacute thyroiditis is also known as? 2

Probably secondary to what?

WHat is it characterized by? 3

What lab is high?

What does the thyroid scan show?

Treatment of choice?

A

de Quervain’s thyroiditis or Granulomatous thyroiditis

Probably secondary to a viral infection

Characterized by

  1. fever and
  2. anterior neck pain.
  3. Exquisitely tender thyroid gland

ESR is high

Thyroid scan shows little or no uptake of radioiodine

Treatment of choice is symptomatic
Complete resolution of symptoms in 90% of patients within months

69
Q

Postpartum (Subacute Lymphocytic Thyroiditis)
onset?

The presence of what increases the risk in pregnant women?

What increases the risk of occurrence?

A

Onset is within 3-12 months post delivery

Presence of TPO anitibodies increases risk

Increased risk of reoccurrence with subsequent pregnancies

25-20% will progress to hypothyroidism within 5 years of delivery

70
Q

Postpartum (Subacute Lymphocytic) symptoms?

2

A
  1. Thyroid gland is NONTENDER

2. Low uptake of RAI

71
Q

Postpartum (Subacute Lymphocytic) treatment?

3

A
  1. Propanolol for tremors and tachycardia
  2. If hypothyroidism develops, Levothyroxine for 6 months to restore normal function
  3. Those who go on to develop permanent hypothyroidism will have to take Levothyroxine for life
72
Q

Iodine Induced – (Jod-Basedow) thyroiditis:

Induced by what?

How do we diagnosis this? 2

A

Induced by contrast agents for angiography or CT scan

  1. Low uptake of radioactive iodine
  2. Absence of antithyroid antibodies
73
Q

Amiodarone Induced thyroiditis:

What is amiodarone?

There are two types. Describe them?

A

Iodinated drug with antiarrhythmic and antianginal properties

Type 1 – occurs in patients w/ underlying thyroid disease
Type 2 – occurs in normal thyroids

74
Q

Chronic thyroiditis types?

2

A

Hashimoto’ s thyroiditis : Previously discussed

Riedel’s struma

75
Q 
What is Riedel’s struma
(who is it seen in?
What is wrong with the gland?
What does it cause? 3)
 and how do we treat it?2
A

(invasive fibrous thyroiditis) is a rare form of thyroiditis seen in middle aged women. The gland is stony hard and adherent to the surrounding structures and may cause symptoms of compression (dysphagia, dyspnea or hoarseness)

Treatment: Tamoxifen, steroids

76
Q

Most common endocrine problem in the US?

A

Thyroid Nodules

77
Q

Thyroid Nodules
are what?

Do they come is groups or solitary?

How are they discovered?

How do they appear on an RAIU?

A

Most often benign neoplasms from follicular epithelium

Usually solitary

Often painless, often discovered during a routine physical exam

Appear as “cold nodules” on RAIU scan

78
Q

Solitary Thyroid Nodule
High risk factors for malignancy

History? 7

Physical findings? 5

Lab/imaging? 3

Treatment?

A

History:

  1. head and neck irradiation, 2. exposure to nuclear radiation,
  2. recent onset,
  3. rapid growth,
  4. young age,
  5. male sex,
  6. familial incidence

Physical:

  1. hard consistency,
  2. fixation,
  3. lymphadenopathy,
  4. vocal cord paralysis,
  5. distant metastasis

Lab/imaging:

  1. elevated calcitonin,
  2. cold nodule,
  3. solid lesion on ultrasound

Levothyroxine therapy: no regression

79
Q

Three things to look out for about the nodule that might mean malignancy?

A

Fine, irregular and fixed

80
Q

Features that favor a benign thyroid nodule?8

A
  1. Family history of Hashimoto’s
  2. Family history of benign thyroid nodule
  3. Symptoms of hypothyroidism or hyperthyroidism
  4. Pain or tenderness associated with nodule
  5. Soft, smooth, mobile
  6. Multinodular without prominent nodule
  7. “Warm nodule” on thyroid scan
  8. Simple cyst on ultrasound
81
Q

Thyroid Cancer
may present how?

What lab will be normal?

How is the diagnosis made?
2

A

May present as painless swelling in the region of the thyroid

Thyroid function tests are usually normal

Diagnosis is made by

  1. fine needle aspiration cytology
  2. Radioactive iodine scanning usually shows malignancies to be hypofunctioning (cold)
82
Q

Whats the 4 types of thyroid cancers and what are the two most common?

A
  1. Papillary – (75% to 85% of cases)
  2. Follicular – (10% to 20% of cases)
  3. Medullary – (5% of cases)
  4. Anaplastic – (less than 5% of cases)
83
Q

Predisposing factors for thyroid cancer?

3

A
  1. Familial medullary carcinomas occur in MENII (multiple endocrine neoplasia type 2)
  2. exposure to ionizing radiation
  3. preexisting thyroid disease
84
Q

Papillary Carcinoma
is often associated with what?

Describe the tumor? 2

Symptoms?

Physical Exam findings? 2

Labs to check?

Prognosis?

Treatment? 3

A

previous exposure to ionizing radiation

Well-differentiated, slow-growing

Hx- Mostly asymptomatic.

PE-

  1. Painless neck mass or
  2. metastatic disease to cervical lymph nodes

Labs- Thyroglobulin levels are elevated

Prognosis-10 year survival rate up to 85%

Treatment-

  1. Thyroidectomy in conjunction with
  2. radioactive iodine
  3. Lifetime levothyroxine
85
Q

Follicular carcinoma:

Describe its growth?

Where does it spread and how?
3 places
2 modes of movement

Prognosis depends on? 2

Treatment? 3

A

Slow growing

  1. Spreads to regional nodes
  2. Hematogenous spread to lung or bone

Prognosis depends on

  1. degree of vascular invasion and
  2. metastases

Treatment-

  1. Thyroidectomy in conjunction with
  2. radioactive iodine
  3. Lifetime levothyroxine
86
Q

Medullary Carcinoma:

Where does this cancer occur?

Often presents how?

What is a unique tumor marker for medullary carcinoma?

Can sometimes be part of what syndrome?

Treatment?

A

Occurs in the C-cells in thyroid

Often presents as a nodule in the upper half of the thyroid gland

Calcitonin is a unique tumor marker for medullary CA, although they remain eucalcimic

Is sometimes part of the MEN syndrome

Treatment is surgical removal

87
Q

Hurthle Cell Carcinoma is usually classified how?

Treatment?

A

Usually classified as follicular thyroid cancer

Cell has a distinctive look under the microscope

Treatment is surgical removal

Endocrinology (23 decks)

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